Certificate of Origin - SAMPLE ONLY

LPH Richardson Chamber of Commerce

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CERTIFICATE OF ORIGIN ­ SAMPLE ONLY

Shipper Name and Address

Forwarding Agent - References

Consignee Name and Address

Notify Party

Exporting Carrier Total Number of Packages

Country of Manufacture Date of Export

Marks & Numbers

Commodity Description

Quantity / Unit of Measure

Weight (kg)

Gross

Net

These commodities, technology or software were exported from the United States of America in accordance with the Export Administration Regulations. Diversion contrary to U.S. law prohibited.

Dated at

on the

day of

20

Authorized Signature: ______________________________________________

NOTARY CERTIFICATE: Sworn to before me this

day of

20

Signature of Notary:

The Richardson Chamber of Commerce, a recognized Chamber of Commerce under the laws of the State of Texas,

has examined the manufacturer's invoice or shipper's affidavit concerning the origin of the merchandise and, according to the

best of its knowledge and belief, finds that the products named originated in the United States of America.

Secretary:

(STAMP)