Attachment 3

Vendor No ____________________

Vendor Name ____________________

AFFIDAVIT OF ORIGIN
Part Number Description of Goods Country of Origin

I, ,
(Name) (Title)

of , do hereby certify that the information set forth above is true

(Name & Address of Vendor)

and correct. If any of the information set forth on the Affidavit should change, I hereby agree to issue a new

Affidavit immediately to the party to whom this Affidavit has been issued.

Signature ____________________________

Date ________________________________