■ 자유무역협정의 이행을 위한 관세법의 특례에 관한 법률 시행규칙 [별지 제12호서식] 아세안회원국과의 협정에 따른 원산지증명서의 서식 (앞쪽) original(duplicate/triplicate) 1.goods consigned from(exporters 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(consignees name, address, country) 3.means of transport and route(as far as known) departure date: vessels 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 countr5.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 signator12.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 authorit13.third country invoicing exhibition back-to-back co 210mm×297mm[백상지 80g/㎡(재활용품)] (뒤쪽) 작 성