На английском языке

(на английском языке)

1. Goods consigned from (Exporter's business name, address, country)

Reference N

GENERALIZED SYSTEM OF PREFERENCES CERTIFICATE OF ORIGIN (Combined declaration and certificate)

FORM A

2. Goods consigned to (Consignee's name, address, country)

Issued in ......................

(country)

See notes overleaf

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

4. For official use

5. Item number

6. Marks and numbers 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. Certification

12. Declaration by the exporter

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

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 those goods in the Generalized System of Preferences for goods exported to

....................................................................

(importing country)

....................................................................

Place and date, signature and stamp of certifying authority

....................................................................

Place and date, signature of authorized signatory