Original(Duplicate/Triplicate)

1. Goods Consigned from(Exporter's business name, address, country)

Reference No.

KOREA-ASEAN FREE TRADE AREA PREFERENTIAL TARIFF CERTIFICATE OF ORIGIN

(Combined Declaration and Certificate)

FORM AK

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)

Departure date:

Vessel's name/Aircraft etc.:

Port of Discharge

4. For Official Use

□ Preferential Treatment Given Under KOREA-ASEAN Free Trade Area Preferential Tariff

□ Preferential Treatment Not Given (Please state reason/s)

..........................................

Signature of Authorised Signatory of the Importing Country

5. Item number

6. Marks and numbers on packages

7. Number and type of packages, description of goods(including quantity where appropriate and HS number of the importing country)

8. Origin Criterion

(See Notes overleaf)

9. Gross weight or other quantity and Value

(FOB only when RVC criterion is used)

10. Number and date of Invoices

11. Declaration by the exporter

The undersigned hereby declares that the above details and statement are correct; that all goods were produced in

.........................................

(Country)

and that they comply with the origin requirements specified for these goods in the KOREA-ASEAN Free Trade Area Preferential Tariff for the goods exported to

......................................

(Importing Country)

......................................

Place and date,

signature of authorised 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 authority

13. □ Third Country Invoicing □ Exhibition □ Back-to-Back CO

가. 수출당사국의 영역에서 완전생산된 물품

WO