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1.Goods consigned from（托运的货物）:
(Exporter’s business name, address, country)（出口商的企业名称，地址，国家）
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Reference No.（参考编号）
Issued in （分在）…………….
(Country)
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5.Tariff item number:（关税项目编号）
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6. Marks and number of Packages（商标和包装件数）：
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7. Number
and kind of packages/
description
of goods:（编号和种包/商品描述）
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8. Origin
criterion
(see notes
overleaf)（原产地 标准 .见说明 背面）
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9. Gross
weight
or other
quantity:（毛重量或其他数量）
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11. Declaration by the exporter :（宣言出口）
The undersigned hereby declares that the above details and statements are correct: that all the goods were produced in（签字在此声明，上述细节和声明是正确的：所有货物生产国和他们遵守这些货物在亚洲太平洋贸易协定对出口货物原产地规定的要求）
……………………………….
(Country)
……………………………….
(Importing Country)
……………………………….
Place and date, signature of authorized
Signatory
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12. Certificate （证书）
It is hereby certified on the basis of control carried out, that the declaration by the exporter is correct.（特此证明控制权的基础上进行，即由出口商的声明是正确的地点和日期，签名 和邮票）
…………………………………
Place and date, signature and Stamp of
Certifying Authority（认证机构）
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国内认证