Schedule Form for Certificate of Origin

1. Goods consigned from (Exporter's business name, address, country)			Reference No. CERTIFICATE OF ORIGIN (Combined declaration and certificate) Issued in REPUBLIC OF KOREA □□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□ (Country) See instrucions overleaf
2. Goods consigned to (consignee's name, address, country)
3. Means of transport and route(as far as known)			4. For official use
5. Item number	6.Marks and numbers of packages	7.Number and kind of packages ; description of goods			8. Origin criterion (see instructions overleaf)	9. Gross weight or other quantity	10. Number and date of invoices
11. Declaration by the exporter The undersigned hereby declares that the above details and statements are correct; that all the goods were produced in REPUBLIC OF KOREA (country) and that they comply with the origin requirements specified for these goods under the Agreement □□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□ (Importing country) □□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□ Place and date, signature of authorized signatory				12. Certification It is hereby certified, on the basis of control carried out, that the declaration by the exporter is correct □□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□ Place and date, signature and stamp of certifying anthority.