本證明書內所列之貨品原產地為 (國別)

本證不得塗改，其經塗改者，無效。This certificate shall be considered null and void in case of any alteration.

申請人（出口人）切結：The exporter hereby declares that：

1.

本證明書內所列之貨品原產地為 (國別)

The goods listed in this certificate originate in

　 (country)

2.上述內容均已據實填報，並遵守「原產地證明書及加工證明書管理辦 法」之規定，如有不實或有違法情事，願依貿易法第28條規定接受行 政處罰。

This certificate is truthfully filled out and in compliance with the “Regulations Governing Certificates of Origin and Certificates of Processing”. Any false statement made in this document or violation of the relevant laws is subject to administrative penalty in accordance with Article 28 of the “Foreign Trade Act”.

8.原進口報單號碼或經貿易局許可之進口證明文件 Import Declaration No. or import document Ref No.

申請人

統一編號

Applicant’s Business Account Number

申請人

名稱、地址

　　　　　　　 Stamp of exporter

本證明書將建檔保存二年。

This certificate shall be preserved and filed for two (2) years.

Authorized signature