Приложение 3. Certificate of origin

Приложение 3

┌───────────────────────────────────────┬─────────────────────────────────┐

│ 1. Exporter (name, address, country │ ORIGINAL N │

│ │ │

│ │ 4169792 │

├───────────────────────────────────────┤ CERTIFICATE OF ORIGIN │

│ 2. Cosignee (name, address, country) │Issued in the Russian Federation │

│ │ │

├───────────────────────────────────────┼─────────────────────────────────┤

│ 3. Means of transport and route │ 4. For official use │

│ │ │

│ 5. Country of origin │ 6. Supplementary details │

│ │ │

├─────────┬─────────────────────────────┴──────────┬───────────┬──────────┤

│ 7. Item │ 8. Description of goods │9. Number │10. Gross │

│ num- │ │ and kind│ weight│

│ ber │ │ of pac- │ or │

│ │ │ kages │ other │

│ │ │ │ quan- │

│ │ │ │ tity │

│ │ │ │ │

├─────────┴─────────────────────────────┬──────────┴───────────┴──────────┤

│11. Certification │12. Declaration by the exporter │

│ It is hereby certified, than the │ The undersigned hereby │

│ declaration by the exporter is │ declares that the above │

│ correct │ details and statements are │

│ │ correct; that the goods │

│ │ are of origin of the country │

│ │ shown in box No 5; than the │

│ │ goods are exported to │

│ │ │

│ │ .............................│

│ │ (importing country) │

│ │ │

│.......................................│.................................│

│Place, date, signature, name and stamp │ Place, date, stamp and signature│

│ of certifying authority │ of authorized signatory │

│ │ │

└───────────────────────────────────────┴─────────────────────────────────┘