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Form Ai: Preferential Tariff Certificate of Origin

This document is a Certificate of Origin form for goods being shipped from Indonesia to India. It contains information about the exporter in Indonesia, the consignee in India, details of the shipment including the transport and departure date, a description of the goods as 2 containers containing sawn wood, and certifications by the exporter and issuing authority in Indonesia that the goods meet the origin criteria for preferential tariff treatment under the ASEAN-India Free Trade Agreement.

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Ipons Ponaryo
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1K views1 page

Form Ai: Preferential Tariff Certificate of Origin

This document is a Certificate of Origin form for goods being shipped from Indonesia to India. It contains information about the exporter in Indonesia, the consignee in India, details of the shipment including the transport and departure date, a description of the goods as 2 containers containing sawn wood, and certifications by the exporter and issuing authority in Indonesia that the goods meet the origin criteria for preferential tariff treatment under the ASEAN-India Free Trade Agreement.

Uploaded by

Ipons Ponaryo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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1. Goods consigned from ( Exporter's business name, address, country) Reference No.

CV. MAROV INTERNATIONAL


JALAN TANJUNG WIRA V/32, RT.05, RW.12 ASEAN-INDIA FREE TRADE AREA
GKB, DS. YOSOWILANGUN, PREFERENTIAL TARIFF
KEC. MANYAR, KAB. GRESIK 61151,
JAWA TIMUR, INDONESIA
CERTIFICATE OF ORIGIN
TEL : +62-81230920864 (Combined Declaration and Certificate)

2. Goods consigned to (Consignee's name, address, country)


FORM AI
BHATTACHARYA TIMBER Issued in INDONESIA
52, BHUPEN BOSE AVENUE (Country)
SHYAMBAZAR, KOLKATA - 700004 WEST BENGAL, INDIA
See Notes Overleaf

3. Means of transport and route (as far as known) 4. For Official Use
Preferential Tariff Treatment Given Under
ASEAN-India Free Trade Area Preferential Tariff
Departure Date MAY 3, 2021

Vessel's name/Aircraft etc. CONTI CANBERRA V.117N


Preferential Tariff Treatment Not Given (Please
state reason/s)
Port of Discharge KOLKATA, INDIA

.........................................................................................
Signature of Authorised Signatory of the Importing
Country

5. Item 6. Marks and 7. Number and type of packages, description of 8. Origin criterion 9. Gross weight or other 10. Number and
number numbers on goods (include quantity where appropriate and (see Notes overleaf) quantity and value (FOB) date of
Packages HS number of the importing country) Invoices

1 2 X 20' CONTAINERS STC : WO 38,823.00 KGM 05/MRV-05/INV/I


21 BUNDLES = 3,440 PCS = 38.8230 CBM USD 17,470.35 V/2021
OF BANGKIRAI SAWN SIZES GRADE-B APRIL 26, 2021
HS CODE : 4409.22.00

11. Declaration by the exporter 12. Certification


The undersigned hereby declares that the above details and It is hereby certified, on the basis of control carried out, that the declaration
statement are correct; that all the goods were produced in by the exporter is correct.

ISSUING OFFICE IN PROVINSI JAWA TIMUR


INDONESIA
........................................................................................................
(Country)

and that they comply with the origin requirements specified for
these goods in the ASEAN-India Free Trade Area Preferential
Tariff for the goods exported to

INDIA
..........................................................................................................
(Importing Country)

GRESIK,
.......................................................................................................... ,
.......................................................................................................................
Place and date, signature of authorised signatory Place and date, signature and stamp of certifying authority

13. Where appropriate please tick:

Third Country Invoicing Exhibition Back-to-Back CO Cumulation


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