1. Products consigned from （Exporter's business name，

　　 address， country）

2. Products consigned to （Consignee's name， address，

　　 country）

Reference No.

ASEAN-CHINA FREE TRADE AREA

PREFERENTIAL TARIFF

CERTIFICATE OF ORIGIN

（Combined Declaration and Certificate）

FORM E

Issued in ______________

（Country）

See Overleaf Notes

3. Means of transport and route （as far as known）

　　 Departure date

　　 Vessel's name/Aircraft etc.

　　 Port of Discharge

4. For Official Use

Preferential Treatment Given

Preferential Treatment Not Given （Please

state reason/s

　 ..................................................................................

Signature of Authorised Signatory of the Importing

Party

5. Item

　　number

6. Marks and

　　numbers on

　　packages

7. Number and type of

　　packages， description of

　　products （including quantity

　　where appropriate and HS

　　number of the importing

　　Party）

8. Origin criteria

　　（see Overleaf

　　Notes）

9. Gross

　　weight or

　　other quantity

　　and value

　　（FOB）

10. Number and

　　　date of

　　　invoices

11. Declaration by the exporter

　　　The undersigned hereby declares that the above

　　　details and statement are correct； that all the products

　　　were produced in

.............................................................

（Country）

　　　and that they comply with the origin requirements

　　　specified for these products in the Rules of Origin for the ACFTA for the products exported to

.............................................................

（Importing Country）

.............................................................

Place and date， signature of

authorised signatory

13

□　Issued Retroactively　　　　　　　 □　　 Exhibition

□　Movement Certificate　　　　　　　□　Third Party Invoicing

12. Certification

　　　It is hereby certified， on the basis of control

　　　carried out， that the declaration by the

　　　exporter is correct.

................................................................................

Place and date， signature and stamp of

certifying authority