Certificate of Origin Example

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CERTIFICATE OF ORIGIN Shipper/exporter (name and address including zip code):

Booking/shipment number:

B/L or AWB number:

Export references:

Consignee (name and address):

Forwarding agent (name and address - references):

Intermediate consignee/notify party (name and address):

Point (state and country) of origin:

Domestic routing / export instructions:

Pre-carriage by:

Place of receipt:

Exporting carrier:

Port of loading/export:

Foreign port of unloading (vessel and air only): Container No. / Seal No. / Marks and Numbers:

Number of Packages:

Transportation method: Place of delivery by on-carrier:

Description of commodities, Model/Serial number, harmonized number

Containerized (vessel only):

YES Gross weight (kg):

NO Measurement

The undersigned _____________ (Owner or Agent), does hereby declare for the above named shipper, the goods as described on the above date and consigned as indicated and are products of the United States of America. Dated at _________ on the ____ day of _______, _______. Sworn to before me this _____ day of _______, _______. ________________________________ Signature of Owner or Agent 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, finds that the products named originated in the United States of America. Secretary __________________________

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