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)LPH Adobe PDF Library 20.6.74