Place and date, signature and stamp of certifying authorized
12、Declaration by the exporter
The undersigned hereby declares that the above details and statements are correct; that all the goods were produced in CHINA and that they comply
(country)
with the origin requirements specified for those goods in the Generalized System of Preferences for goods exported to
importing country
Place and date, signature of authorized signatory
普惠制原产地证
1、Goods consigned from (Exporter’s
Business name, address, country)
2、Goods consigned to (Consignee’s
Name, address, country)
3、Means of transport and route (as far as known)
4、For official use
5、Item
number
6、Marks and
number of
packages
7、Number and kind
packages;
description of goods
8、Origin criterion (see Notes overleaf)
9、Gross weight or other quantity)
10、Number and date of invoices
11、Certification
It is hereby certified, on the basis of control carried out, that the declaration by the exporter is correct.
签证当局签署
12、出口商声明
兹特声明上述详细内容正确无误，货物全部为中国出产，并符合普惠制规定出口至
（进口国）货物的原产地要求。
受权签字人
签名
签名日期、地点
1、发货地方
（出口商名址国别）
2、收货地点
（收货人名址国别）
3、运输工具、路线（尽量详细）
证号：
普惠制原产地证书
格式A
中华人民共和国签发
（见背面备注）
4、（不填）
5、项号
6、标志、号码
7、件数、货名
8、产地成份比例
9、毛重、数量
10、发票号码、日期
11、签证
兹证明：经检验出口商申报内容无误。
签证日期、地点
Reference No.
GENERALIZED SYSTEN OF
PREFERENCES CERTIFICATE OF ORIGIN
(Combined declaration and certificate)
FORM A
Issued in P. R. CHINA
(country)
See Notes overleaf