SAMPLE CERTIFICATE OF ORIGIN
Asia-Pacific Trade Agreement
(Combined declaration and certificate)
1.Goods consigned from:
(Exporter’s business name, address, country)
Reference No.
Issued in …………….
(Country)
2. Goods consigned to:
(Consignee’s name, address, country)
3.For Official use
4. Means of transport and route:
5.Tariff item number: 6. Marks and number of Packages: 7. Number
and kind of packages/
description
of goods:
8. Origin
criterion
(see notes
overleaf) 9. Gross
weight
or other
quantity: 10. Number and date of invoices:
11. Declaration by the exporter :
The undersigned hereby declares that the above details and statements are correct: that all the goods were produced in

……………………………….
(Country)
and that they comply with the origin requirements specified for these goods in the Asia-Pacific Trade Agreement for goods exported to

……………………………….
(importing Country)
……………………………….
Place and date, signature of authorized
Signatory 12. Certificate
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