Certificate of Origin
Invoice Number(s): _____________________
Exporter Name: _______________________ Name of Shipping Company: ____________________
Complete Address: _____________________ Complete Address: __________________________
Location File Numbers
Name of Consignee Address
Transport Information Shipping Number
Invoice Information Country of Origin
Description of Merchandise: Quantity of Merchandise:
_________________________________ __________________________________
_________________________________ __________________________________
_________________________________ __________________________________
_________________________________
Weight of Merchandise:
_________________________________
_________________________________
_________________________________ __________________________________
_________________________________ __________________________________
__ __________________________________
The authorizing official hereby acknowledges the specified country of origin of the
merchandise listed above.
Name of Exporting Agent: ________________________________________
Authorizing Official: __________________ Shipper’s Signature: _______________________
Address: __________________________________________________________________________
________________________________________________________________________________
Date: ----/ -----/ -------------
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