CERTIFICATE OF ORIGIN FORM

The undersigned
OWNER OR AGENT
NAME AND ADDRESS OF SHIPPER
Declares that the following mentioned goods shipped on	on the date
consigned to:
are the product of the United States of America.

SHIPPER NAME AND ADDRESS	FORWARDING AGENT
CONSIGNEE NAME AND ADDRESS	NOTIFY PARTY
EXPORTING CARRIER	COUNTRY OF MANUFACTURE
TOTAL NUMBER OF PACKAGES	DATE OF EXPORT

MARKS AND NUMBERS	COMMODITY DESCRIPTION	QUANTITY / UNIT OF MEASURE	WEIGHT IN KG
GROSS	NET

Sworn to before me this	day of	, 20
SIGNATURE OF OWNER OR AGENT

The
a recognized Chamber of Commerce under the laws of the state of	,
has examined the manufacturer’s invoice or shipper’s affidavit concerning the origin of the merchandise and, according to the best of its knowledge and belief, finds that the products named originated in the United States of America.
SECRETARY

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