1.出口人名稱及地址 Exporter’s Name and Address CERTIFICATE NO.
Page
CERTIFICATE OF PROCESSING
(Issued in Taiwan)
APPLICATION
2.進口人名稱及地址Importer’s Name and Address
3.裝船日On Board Date
4.船(機)名/航(班)次Vessel/Flight No.
6.卸貨港 Port of Discharge 7.目的地國Country of Destination
8. 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 9.數量/單位Quantity/Unit
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 applicant (exporter) hereby declares that：
1.本證明書內所列之貨品係在臺灣加工。
The goods listed in this certificate were processed 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。
10.原產國之原產地證明書號碼、原進口報單號碼或經貿易局許可之 進口證明文件
Certificate of Origin No. or Import Declaration No. or Import document Ref No.
11.加工廠商名稱及地址Processing firm’s Name and Address
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”.
申
請人（出口人）統一編號
Applicant’s (exporter) Business Account Number申
請人（出口人）名稱、地址
Applicant’s (exporter) Name and AddressStamp of exporter
茲證明本證明書內所列之貨品在臺灣加工，本證明書將建檔保 存二年。
It is hereby certified that the goods described in this certificate were processed in Taiwan, and that this certificate shall be preserved and filed for two (2) years.
Authorized signature
1. Exporter’s Name and Address CERTIFICATE NO.
Page
CERTIFICATE OF PROCESSING
(Issued in Taiwan)
ORIGINAL
2. Importer’s Name and Address
3. On Board date 4. Vessel/Flight No.
6. Port of Discharge 7. Country of Destination
8. Description of Goods; Packaging Marks and Numbers 9. Quantity/Unit
This certificate shall be considered null and void in case of any alteration.
Certification
It is hereby certified that the goods described in this certificate originate in____________ and were processed in Taiwan.
