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1. Goods consigned from (Exporter's business name, address, country)
1004914/BJM/2023

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Reference No.

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PT ELECTRA GLOBAL
JL. KUTILANG KOMP. TIA PERMATA RESORT NO. 07 RT. 002 RW. 005, KOMET,

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BANJARBARU UTARA, BANJARBARU, KALIMANTAN SELATAN, 70711 ASEAN TRADE IN GOODS AGREEMENT

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CERTIFICATE OF ORIGIN

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or (Combined Declaration and Certificate)

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FORM D
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2. Goods consigned to (Consignee's name, address, country)
F

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d Issued in INDONESIA

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KAMPOT CEMENT CO., LTD.
us kan

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(Country)
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NO. 43, MAYBANK TOWER, 6-7 FLOOR, PREAH NORODOM BOULEVARD
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ed

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SANGKAT PHSAR THMEY III, KHAN DAUN PENH, PHNOM PENH, CAMBODIA
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TEL: (855)23996859, VAT: L001-100087507 See Overleaf Notes
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3. Means of transport and route (as far as known) 4. For Official Use
i

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Preferential Treatment Given Under ASEAN
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Departure Date NOVEMBER 11, 2023
pl

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Trade in Goods Agreement
te cet

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uk

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uk
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nt

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Preferential Treatment Not Given (Please
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in
Vessel's name/Aircraft etc. MV. MARTIN ISLAND State reason's)
pr

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Port of Discharge KAMPOT
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Signature of Authorised Signatory of the Customs Authority of the
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Importing Country
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5. Item 6. Marks and numbers 7. Number and type of packages, description 8. Origin criterion 9. Gross weight or other 10. Number and
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number on packages of goods (including quantity where (see Overleaf Notes) Quantity and Value date of
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appropriate (FOB) where RVC is Invoices
and HS number of the importing country) applied
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Pr se

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1 NO MARK INDONESIAN STEAM COAL IN BULK "WO" 28,057.000 TNE PRO-INV/006/EG/
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IN BULK XI/2023

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PORT OF DISCHARGE: KAMPOT NOVEMBER 11,
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Fo

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INTERNATIONAL PORT, CAMBODIA 2023
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us kan

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cl

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TNE EQUALS METRIC TON (MT) TLAOB-23A001
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HS: 27011900 NOVEMBER 11,
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ot igu

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2023
d

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ON BEHALF OF
ca dak

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THAILAND ANTHRACITE CO., LTD.
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it

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nn

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240/40 AYODHAYA TOWER 20TH FLOOR,
in

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in
RATCHADAPISEK ROAD, HUAYKWANG,
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ka

ka

ka
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BANGKOK 10310
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ta
pl

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THAILAND
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ce
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uk
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nt

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11. Declaration by the exporter 12. Certification
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e-

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The undersigned hereby declares that the above details and statement It is hereby certified, on the basis of control carried out, that the declaration by
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are correct; that all the goods were produced in the exporter is correct.
ed

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ot igu

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d

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INDONESIA ISSUING OFFICE IN PROVINSI KALIMANTAN

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(Country) SELATAN
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and that they comply with the origin requirements specified for these
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pl

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goods in the ASEAN Trade in Goods Agreement for the goods

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exported to
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CAMBODIA
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(Importing Country)
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BANJARBARU, NOVEMBER 15, 2023

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Place and date, signature of authorized signatory

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13. v
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Third Country Invoicing Exhibition

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Accumulation De Minimis
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RIZKI ADHANI FADILA

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Back-to-Back CO v Issued Retroactively BANJARMASIN, NOVEMBER 15, 2023

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Partial Cumulation Place and date, signature and stamp of certifying authority
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