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