US Certificate of Origin

The undersigned ______________________________________________________________________________________________

(Owner or Agent)

____________________________________________________________________________________________________________
(Name and Address of Shipper)

declares that the following mentioned goods shipped on ______________________________ on the date ____________consigned to:

____________________________________________________________________________________________________________

are the product of the United States of America.

NO. OF
WEIGHT IN KILOS
PKGS
MARKS AND NUMBERS DESCRIPTION
BOXES
GROSS
OR CASES
Bill of Lading/Air Waybill No.:

Sworn to before me

this ______________ day of __________________ 20___ ______________________________________________________

Signature of Owner or Agent

The ____________________________________________________________________________________________________________________

a recognized Chamber of Commerce under the laws of the State of _____________________________________, has examined the manufacturer’s
invoice or shipper’s affidavit concerning the origin of the merchandise and according to the best of its knowledge and belief, finds that the products
named originated in the United States of North America.

Secretary___________________________________________