75043224742

1. Goods consigned from (Exporter's business name, address, country) Reference No. 0028984/KTG/2018
PT PARDIC JAYA CHEMICALS
JL. GATOT SUBROTO KM 1 ,KEL. CIBODAS
KEC. CIBODAS KOTA TANGERANG 15138
ASEAN TRADE IN GOODS AGREEMENT
BANTEN - INDONESIA ASEAN INDUSTRIAL COOPERATION SCHEME
TAX ID : 01.000.132.9-052.000 CERTIFICATE OF ORIGIN
2. Goods consigned to (Consignee's name, address, country) (Combined Declaration and Certificate)
DIC (VIETNAM) CO., LTD FORM D
31 VSIP, STREET NO.6, VSIP INDUSTRIAL PARK, Issued in INDONESIA
THUAN AN TOWN, BINH DUONG PROVINCE, VIETNAM (Country)
See Overleaf Notes

3. Means of transport and route (as far as known) 4. For Official Use

Preferential Treatment Given Under ASEAN

Departure Date JULY 30, 2018 Trade in Goods Agreement

Preferential Treatment Given Under ASEAN

Vessel's name/Aircraft etc. CAPE MAHON /V.18007N Industrial Cooperation Scheme

Preferential Treatment Not Given (Please

State reason's)
Port of Discharge HOCHIMINH, VIETNAM
.................................................................................................................
Signature of Authorised Signatory of the Importing Country

5. Item 6. Marks and numbers 7. Number and type of packages, description 8. Origin criterion 9. Gross weight or other 10. Number and
number on packages of goods (including quantity where (see Overleaf Notes) Quantity and Value date of
appropriate (FOB) where RVC is Invoices
and HS number of the importing country) applied

1 DIC (VIETNAM) 320 CANS OF : RVC 50% 6,400 KGM 2960026267

PO-4509340038 DICDRY LX-420-A (SIX THOUSAND FOUR JULY 25, 2018
NO. 1 - 1,920 HS: 3909.50.00 HUNDRED)
MADE IN INDONESIA USD 13,489.66

2 DIC (VIETNAM) 320 CANS OF : RVC 50% 6,400 KGM 2960026267

PO-4509340038 DICDRY LX-420-A (SIX THOUSAND FOUR JULY 25, 2018
NO. 1 - 1,920 HS: 3909.50.00 HUNDRED)
MADE IN INDONESIA USD 13,489.66

3 DIC (VIETNAM) 320 CANS OF : RVC 50% 6,400 KGM 2960026267

PO-4509340038 DICDRY LX-420-A (SIX THOUSAND FOUR JULY 25, 2018
NO. 1 - 1,920 HS: 3909.50.00 HUNDRED)
MADE IN INDONESIA USD 13,489.66

4 DIC (VIETNAM) 320 CANS OF : RVC 50% 6,400 KGM 2960026267

PO-4509340038 DICDRY LX-SP-75 (SIX THOUSAND FOUR JULY 25, 2018
NO. 1 - 1,920 HS: 3909.50.00 HUNDRED)
MADE IN INDONESIA USD 14,180.86

5 DIC (VIETNAM) 320 CANS OF : RVC 50% 6,400 KGM 2960026267

PO-4509340038 DICDRY LX-SP-75 (SIX THOUSAND FOUR JULY 25, 2018
NO. 1 - 1,920 HS: 3909.50.00 HUNDRED)
MADE IN INDONESIA USD 14,180.86

11. Declaration by the exporter 12. Certification

The undersigned hereby declares that the above details and statement It is hereby certified, on the basis of control carried out, that the declaration
are correct; that all the goods were produced in by the exporter is correct.

INDONESIA
ISSUING OFFICE IN KOTA TANGERANG
......................................................................................................................
(Country)
and that they comply with the origin requirements specified for
these goods in the ASEAN Trade in Goods Agreement for the goods
exported to

VIET NAM
......................................................................................................................
(Importing Country)

TANGERANG, AUGUST 2, 2018

......................................................................................................................
Place and date, signature of authorised signatory

13.
Third Country Invoicing Exhibition

Accumulation De Minimis OKE SULENDRO SETYO RACHMAN

Back-to-Back CO v Issued Retroactively TANGERANG, AUGUST 2, 2018

.......................................................................................................................................
Partial Cumulation Place and date, signature and stamp of certifying authority

Page 1 / 2
 75043224742
1. Goods consigned from (Exporter's business name, address, country) Reference No. 0028984/KTG/2018
PT PARDIC JAYA CHEMICALS
JL. GATOT SUBROTO KM 1 ,KEL. CIBODAS
KEC. CIBODAS KOTA TANGERANG 15138
ASEAN TRADE IN GOODS AGREEMENT
BANTEN - INDONESIA ASEAN INDUSTRIAL COOPERATION SCHEME
TAX ID : 01.000.132.9-052.000 CERTIFICATE OF ORIGIN
2. Goods consigned to (Consignee's name, address, country) (Combined Declaration and Certificate)
DIC (VIETNAM) CO., LTD FORM D
31 VSIP, STREET NO.6, VSIP INDUSTRIAL PARK, Issued in INDONESIA
THUAN AN TOWN, BINH DUONG PROVINCE, VIETNAM (Country)
See Overleaf Notes

3. Means of transport and route (as far as known) 4. For Official Use

Preferential Treatment Given Under ASEAN

Departure Date JULY 30, 2018 Trade in Goods Agreement

Preferential Treatment Given Under ASEAN

Vessel's name/Aircraft etc. CAPE MAHON /V.18007N Industrial Cooperation Scheme

Preferential Treatment Not Given (Please

State reason's)
Port of Discharge HOCHIMINH, VIETNAM
.................................................................................................................
Signature of Authorised Signatory of the Importing Country

5. Item 6. Marks and numbers 7. Number and type of packages, description 8. Origin criterion 9. Gross weight or other 10. Number and
number on packages of goods (including quantity where (see Overleaf Notes) Quantity and Value date of
appropriate (FOB) where RVC is Invoices
and HS number of the importing country) applied

6 DIC (VIETNAM) 320 CANS OF : RVC 50% 6,400 KGM 2960026267

PO-4509340038 DICDRY LX-SP-75 (SIX THOUSAND FOUR JULY 25, 2018
NO. 1 - 1,920 HS: 3909.50.00 HUNDRED)
MADE IN INDONESIA USD 14,180.86

11. Declaration by the exporter 12. Certification

The undersigned hereby declares that the above details and statement It is hereby certified, on the basis of control carried out, that the declaration
are correct; that all the goods were produced in by the exporter is correct.

INDONESIA
ISSUING OFFICE IN KOTA TANGERANG
......................................................................................................................
(Country)
and that they comply with the origin requirements specified for
these goods in the ASEAN Trade in Goods Agreement for the goods
exported to

VIET NAM
......................................................................................................................
(Importing Country)

TANGERANG, AUGUST 2, 2018

......................................................................................................................
Place and date, signature of authorised signatory

13.
Third Country Invoicing Exhibition

Accumulation De Minimis OKE SULENDRO SETYO RACHMAN

Back-to-Back CO v Issued Retroactively TANGERANG, AUGUST 2, 2018

.......................................................................................................................................
Partial Cumulation Place and date, signature and stamp of certifying authority

Page 2 / 2