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Certificate of Origin
Shipper Name and Address Forwarding Agent - References
Consignee Name and Address Notify Party
Exporting Carrier Country of Manufacture
Total Number of Packages Date of Export
Quantity / Weight (kg)
Unit of Measure Gross Net
These commodities, technology or software were exported from the United States of America in accordance with the Export
Administration Regulations. Diversion contrary to U.S. law prohibited.
Dated at ____________ on the ______ day of _______________ , 20 ____ . Signature of Notary: ________________________
Sworn to before me this _____ day of_______________ , 20 _____ . Signature of Notary: ______________________________
The _________________________ , a recognized Chamber of Commerce under the laws of the State of_____________________
has examined the manufacturer’s invoice or shipper’s affidavit concerning the origin of the merchandise and, according to the best
of its knowledge and belief, finds that the products named originated in the _____________________________ .
Marks & Numbers Commodity Description
FXF - SL235/503