Форма дополнительного листа сертификата о происхождении товара общей формы на английском языке

It is hereby certified, that the declaration by the exporter is correct

The undersigned hereby declares that the above details and statements are correct; that the goods are of origin of the country shown in box No 5; that the goods are exported to

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(importing country)

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Place, date, signature, name and stamp of certifying authority

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Place, date, stamp and signature of authorized signatory