Соглашение о гармонизированной системе определения происхождения товаров, вывозимых с таможенной территории Евразийского экономического союза

1. Consignor/exporter (name and address)

4. N _______

CERTIFICATE OF ORIGIN

2. Consignee/importer (name and address)

Issued in

(country)

For submission to

(country)

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

5. For official use

6. N

7. Number and kind of packages

8. Description of goods

9. Quantity of goods

10. Certification

11. Declaration by the applicant

It is hereby certified, on the basis
of control carried out, that the declaration
by the applicant is correct

The undersigned hereby declares that the above details are correct, that all goods are originating in

(country)

and comply with the origin requirements specified for those goods

Signature

Date

Stamp

Signature

Date

Stamp