Certificate of Origin

The undersigned

(Owner or Agent)

of

(Name and Address of Shipper)

declares that the goods shipped via

on the date

consigned to:

is a product of

.

(Country)

MARKS AND NUMBERS

NO. OF

GROSS

DESCRIPTION

PKGS

WEIGHT

OR CASES

(kilos)

Bill of Lading or Air Waybill No:

Sworn before me

this

day of

20

Signature of Owner or Agent

The

a recognized Chamber of Commerce under the laws of the

(State, Province, etc.)

of

(Country)

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

Secretary

(Country)

Chamber Seal