1. Goods consigned from (Exporter's business name, address, country) Reference No.

PT NUSAROMA ESSENTIAL INDONESIA

GRAHA MAMPANG LT 3, JALAN MAMPANG PRAPATAN RAYA NO 100, DUREN
TIGA,PANCORAN, JAKARTA SELATAN, DKI JAKARTA
ASEAN TRADE IN GOODS AGREEMENT
INDONESIA ASEAN INDUSTRIAL COOPERATION SCHEME
CERTIFICATE OF ORIGIN
2. Goods consigned to (Consignee's name, address, country) (Combined Declaration and Certificate)
S. TONG CHEMICALS .CO.LTD FORM D
410/78-83 RATCHADAPISEK ROAD. HUAYKWANG SAMSENOK, BANGKOK 10310 Issued in INDONESIA
THAILAND TELP + 66 2 541 53446 ATTN MR NUMPHOL V (GONG) (Country)
THAILAND
See Overleaf Notes

3. Means of transport and route (as far as known) 4. For Official Use

Preferential Treatment Given Under ASEAN

Departure Date JANUARY 30, 2017 Trade in Goods Agreement

Preferential Treatment Given Under ASEAN

Vessel's name/Aircraft etc. GA 862 Industrial Cooperation Scheme

Preferential Treatment Not Given (Please

State reason's)
Port of Discharge BANGKOK
.................................................................................................................
Signature of Authorised Signatory of the Importing Country

5. Item 6. Marks and 7. Number and type of packages, description 8. Origin criterion 9. Gross weight or other 10. Number and
number numbers on of goods (including quantity where (see Overleaf Notes) Quantity and Value date of
packages appropriate (FOB) where RVC is Invoices
and HS number of the importing country) applied

1 EUGENOL USP S NET 1 PX WO 12 DR INV/NSR-003/01/20

WEIGHT 300 KG DRUM 1 PALLET = 12 JERRY CAN HDPE 25 KG (TWELVE) 17
1-12 S TONG EUGENOL USP = 300 KGM JANUARY 19, 2017
CHEMICALS HS: 2909500000
BANGKOK-THAILAND

11. Declaration by the exporter 12. Certification

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

INDONESIA
MUNICIPALITY OFFICE IN CAKUNG
......................................................................................................................
(Country)
and that they comply with the origin requirements specified for
these goods in the ASEAN Trade in Goods Agreement for the goods
exported to

THAILAND
......................................................................................................................
(Importing Country)

JAKARTA SELATAN,
......................................................................................................................
Place and date, signature of authorised signatory

13.
Third Country Invoicing Exhibition

Accumulation De Minimis

Back-to-Back CO Issued Retroactively

,
.......................................................................................................................................
Partial Cumulation
Place and date, signature and stamp of certifying authority

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