df s
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臺灣。
The goods listed in this certificate originate in Taiwan.
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
8.生產廠商名稱及地址 Producer’s Name and Address 1.出口人名稱及地址Exporter’s Name and Address
Page of
CERTIFICATE OF ORIGIN
(Issued in Taiwan)
APPLICATION
申請書
2.進口人名稱及地址 Importer’s Name and Address
3. 裝貨港Port of Loading
4. 卸貨港Port of Discharge 5. 目的地國Country of Destination
6. 貨品明細含名稱、型號、規格、包裝標誌及編號Description of Goods; Packaging Marks and Numbers 7.數量/單位 Quantity/Unit
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”.
申
請人（出口人）統一編號
Applicant’s Business Account Number申
請人（出口人）名稱、地址
Applicant’s Name and AddressStamp of exporter
茲證明本證明書內所列之貨品原產地為臺灣，本證明書將建檔 保存二年。
It is hereby certified that the goods described in this certificate originate in Taiwan, and that this certificate shall be preserved and filed for two (2) years.
Authorized signature
This certificate shall be considered null and void in case of any alteration.
COMMODITY DESCRIPTION SUPPLEMENT 申請書
CERTIFICATE NO.
Page of
6. Description of Goods; Packaging Marks and Numbers 7. Quantity/Unit