1. Goods consigned from(exporter's business name, address, country)			Reference No GENERALIZED SYSTEM OF PREFERENCES CERTIFICATE OF ORIGIN (Combined declaration and Certificate) FORM A Issued in □□□□□□□□□□□□□□ (Country) See Notes Overleaf
2. Goods consigned to (consignee's name, address, country)
3. Means of transport and route(as far as known) FROM : TO : BY :			4. For official use
5.Item num-ber	6.marks and numbers of package	7.Number and kind of packages; description of goods			8. Origin criterion (see notes overleaf)	9. Gross weight or other quantity	10. Number and date of invoice
11. 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 authority				12. Declaration by the exporter The undersigned hereby declares that the above details and statements are correct; that all the goods were produced in and that they comply with the origin requirements specified for those goods in the generalized system of preferences for goods exported to Place and date, signature of authorized Signatory