Certificate of origin (Combined declaration and certificate) (Form A)

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

│1. Goods consigned from │Reference N │

│(exporter's business name, │ │

│address, country) │GENERALIZED SYSTEM OF PREFERENCES│

│ │ │

│ │ CERTIFICATE OF ORIGIN │

├──────────────────────────────┤ │

│2. Goods consigned to │ (Combined declaration │

│(consignee's name, address, │ and certificate) │

│country) │ │

│ │ FORM A │

│ │ │

│ │ Issued in ____________________ │

│ │ (country) │

│ │ │

│ │ See notes overleaf│

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

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

│route (as far as known) │ │

│ │ │

│ │ │

│ │ │

│ │ │

│ │ │

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

│5. Item│6. Marks │7. Number and│8. Origin │9. Gross│10. Number │

│number │and │kind of │criterion │weight │and date of│

│ │numbers of│packages; │(see notes│or other│invoices │

│ │packages │description │overleaf) │guantity│ │

│ │ │of goods │ │ │ │

│ │ │ │ │ │ │

│ │ │ │ │ │ │

│ │ │ │ │ │ │

│ │ │ │ │ │ │

│ │ │ │ │ │ │

│ │ │ │ │ │ │

│ │ │ │ │ │ │

│ │ │ │ │ │ │

│ │ │ │ │ │ │

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

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

│It is hereby certified, on │The undersigned hereby declares │

│the basis of control carried │that the above details and │

│out, that the declaration │statements are correct; that all │

│by the exporter is correct │the goods were produced in │

│ │__________________________________│

│ │ (county) │

│ │ │

│ │and that they comply with the │

│ │origin reguirements specified │

│ │for those goods in the generalized│

│ │system of preferences for goods │

│ │exported to │

│ │__________________________________│

│ │ (importing country) │

│ │ │

│_____________________________│__________________________________│

│ Place and date, signature │ Place and date, signature of │

│ and stamp of certifying │ authorized signatory │

│ authority │ │

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