Reference No. 

5. Item

6. Marks and

7. Number and type of

8. Origin criterion

9. Gross weight

10. Number and

number

numbers on

packages, description of

(see Overleaf Notes)

or other quantity

date of

packages

goods (including quantity

and value

invoices

where appropriate and HS

code of the good in the importing

country)

(FOB only when RVC criterion is used)

11. Declaration by the exporter

12. Certification

The undersigned hereby declares that the above

It is hereby certified, on the basis of control

details and statement are correct, that all the goods

carried out, that the declaration by the

were produced in

exporter is correct.

.............................................................

(Country)

and that they comply with the origin requirements

specified for these goods in the Viet Nam-Korea

Free Trade Agreement for the goods

exported to

.............................................................

(Importing Country)

.............................................................

................................................................................

Place and date, signature of

Place and date, signature and stamp of

authorized signatory

certifying authority

13. Remarks