EXPORTER (Full Name & Address)

Certificate No.

CONSIGNEE (If required)

Carrier

Part of Discharge

Mark(s) & Number(1)

CERTIFICATE OF

HONG KONG ORIGIN

Port of Loading

Date of Departure".

Country of Destination

Final Destination. If on Carriage

(on or about)

Number and Type of Packages & Description of Goods

Factory Number

Quantity or Weight (in words and figures)

Brand Na

Labels fif

SPECIMEN

I hereby certify that the goods described above were made in Hong Kong. I further certify that the goods described above meet the origin rules of the European Economic Community.*

*The certification may be stamped on the certificate.

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