1. Products consigned from (Exporter's business name, address, country) Reference No.

PT. BAYAS BIOFUELS

GEDUNG MENARA PALMA LT. 27 ASEAN-CHINA FREE TRADE AREA
JL. H.R. RASUNA SAID, BLOK X-2 KAV 6 PREFERENTIAL TARIFF
KUNINGAN, JAKARTA SELATAN 12950,
INDONESIA
CERTIFICATE OF ORIGIN
(Combined Declaration and Certificate)
2. Products consigned to (Consignee's name, address, country)
FORM E
XIAMEN C AND D ENERGY RESOURCES CO., LTD.
22/F., C AND D INTERNATIONAL BUILDING,
NO. 1699 HUANDAO EAST ROAD, XIAMEN Issued in INDONESIA
361008, CHINA
TEL: 0592-2263526 FAX: 0592-2076986
See Overleaf Notes

3. Means of transport and route (as far as known) 4. For Official use

Departure Date NOVEMBER 24, 2016 Preferential Treatment Given

Vessel's name/Aircraft etc. MT SHAN YI V. 1628VC Preferential Treatment Not Given (Please state reason/s)

.................................................................................................................
Port of Discharge XIAMEN, CHINA
Signature of Authorised Signatory of the Importing Party

5. Item 6. Marks and 7. Number and type of packages, 8. Origin criteria 9. Gross weight 10. Number and
number numbers of description of products (including (see Overleaf or other quantity date of
packages quantity where appropriate and Notes) and value (FOB) invoices
HS number of the importing Party)

1 NO MARK 3,007.739 TNE CRUDE GLYCERINE WO 3,007.739 TNE 001/GLY-BBF/XI/2016

(THREE THOUSAND NOVEMBER 24, 2016
PACKING : IN BULK AND SEVEN POINT
HS: 1520000000 SEVEN HUNDRED
AND THIRTY-NINE)
APEIRON AGROCOMMODITIES PTE LTD USD 505,300.15
6 EU TONG SEN ST. NO. 08-05 THE
CENTRAL
059817

-
SINGAPORE

11. Declaration by the exporter 12. Certification

The undersigned hereby declares that the above details and statement are It is hereby certified, on the basis of control carried out, that the declaration by
correct; that all the products were produced in the exporter is correct

INDONESIA DISTRICT OFFICE IN TEMBILAHAN

.....................................................................
(Country)

and that they comply with the origin requirements specified for these
products in the Rules of Origin for the ACFTA for the products exported to

CHINA
.....................................................................
(Importing Country)

JAKARTA,
..........................................................................................................
Place and date, signature of authorised signatory

13.
v
Issued Retroactively Exhibition ,
.............................................................................................................
Movement Certificate v Third Party Invoicing Place and date, signature and stamp of certifying authority

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