ORIGINAL
Reference No. VN-KR ...
1. Goods consigned from (Exporter's business name, address, country)CLOVER
FILTER VINA CO., LTD
LOT V-2.1, N1 ROAD, QUE VO II INDUSTRIAL ZONE, NGOC XA COMMUNE, ASEAN-KOREA FREE TRADE AREA
QUE VO TOWN, BAC NINH PROVINCE PREFERENTIAL TARIFF
VIET NAM CERTIFICATE OF ORIGIN
(Combined Declaration and Certificate)
2. Goods consigned to (Consignee's name, address, country)
FORM AK
MS FILTER CO., LTD Issued in VIET NAM
15-50, 1ST FLOOR, SUWORAM-GIL, PYEONGTAEK-SI, (Country)
GYEONGGI-DO, KOREA 17704
See Notes Overleaf
SOUTH KOREA
3. Means of transport and route (as far as known) 4. For Official Use
Departure Date: 14/12/2024 ☐ Preferential Treatment Given Under ASEAN-Korea
Vessel's name/Aircraft etc.: DONGJIN CONTINENTAL/0181E Free Trade Area Preferential Tariff
Port of Discharge: INCHEON (KOREA (REPUBLIC))
☐ Preferential Treatment Not Given
(Please state reason/s)
Signature of Authorised Signatory of the Importing Country
5. Item number 6. Marks and numbers on 7. Number and type of packages, description of 8. Origin criterion 9. Gross weight or 10. Number and
packages goods (including quantity where appropriate and (see Notes other quantity and date of Invoices
HS number of the importing country) Overleaf) value (FOB only
when RVC
criterion is used)
1 N/M HEPA 610*915*292 CFV-13122024
HS CODE: 84213990 CTH 88.00 PIECE
DATE:13/12/2024
88 BOX
11. Declaration by the exporter 12. Certification
The undersigned hereby declares that the above details and It is hereby certified, on the basis of control carried out, that the
statements are correct; that all the goods were produced in declaration by the exporter is correct.
VIET NAM
(Country)
and that they comply with the origin requirements specified for
these goods in the ASEAN-KOREA Free Trade Area Preferential
Tariff for the goods exported to
SOUTH KOREA
(Importing Country)
BAC NINH, .../2024 HA NOI, .../2024
Place and date, signature of authorised signatory Place and date, signature and stamp of certifying authority
13. Third Country Invoicing Exhibition Back-to-Back CO
Page 1 / 4
