1 ConsignorAvsendsre No.

GR M L005689
ORIGINAT
SANTASALO GmbH.
Otto-l lahn-Stl.51
GERMANY EUROPEAN COMMUNITY
2 Consignee Mottogare EUROPEISKA GEM ENSKAPEN

Asia Port Trading CO, Sdn Bhd cq. CERTIFICATE OF ORIGIN

CV. Trijaya Anugrah Lestari URSPRUNGSCERTIFIKAT
Jl. Sutomo No.27-G, North Sumatera
20232 Medan 3 Country of origin Ursprungsland
lndonesia
GERMANY

4 Transport details (optional) 5. Remark4nmdrkningor

Upplysningar om tronspoften (frivillig uppstft)

SEA FREIGHT Contract No. 035fiA1-APT/1 1-15

6 ltem number, markt numbers, number and kind of packages; description of goods 7. Quantity
Ldpnummer, kollimiirkning, nummer, ontol och slag; varubeskrivning Mdngd
SANTASALO GEAR BOX, S/N W20451 1 SET

8 The undersigned authority certifies that the goods described above originate in the country shown in box 3.
Undertecknad myndighethrganisotion bekriiftar att ovan beskrlvna voror hdr sitt ursprung I det lond som anges, rutd 3.

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Place and date oT issue, signature and stamp of competent authority
Ort och datum f iir utfitrdandet,den behdriga myndighetens/orEanisationens nomn, underckrlft och stiimpel.