1.Exporter’s Name and Address (出口商名稱及地址)
BAN of Applicant(營 利 事 業 統 一
編號) CERTIFICATE NO.
CERTIFICATE OF ORIGIN
(Issued in Taiwan, R.O.C)
APPLICATION
2.Importer’s Name and Address(進口商名稱及地址)
Producer’s Name and Address(製造商名稱及地址)
3.Departure Date (on or
about) (離港日期) 4.Vessel/Flight No(輪船或飛機名稱) 5. Place of Loading (裝貨港)
6. Port of Discharge (卸貨港)
7.Country of Destination (目的地國別)
8. CCC Code
(貨品分類號列) 9. Description of Goods; Packaging Marks and Numbers
(貨品明細含名稱、型號、規格、包裝標誌)
10. Quantity/Unit (數量/單位)
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.
出口人切結：
1.本證明書內所列之貨品原產地為台灣。
2.上述內容均已據實填報，並遵守「原產地證明書管理辦法」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。
The exporter hereby declares that：
1. The goods listed in this certificate originate in Taiwan.
2. This certificate is truthfully filled out and in compliance with the
“Regulations Governing Issuance of Certificate of Origin”. 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”.
Stamp of exporter
茲證明本證明書內所列之貨品原產地為台灣，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 a copy of this certificate shall be preserved and filed for two (2) years.
The Bureau of Foreign Trade, MOEA has entrusted (簽發單位英文名稱) with issue of this certificate.
