Certificate of Origin

The undersigned
(Owner or Agent)
for declares
(Name and Address of Shipper)
the following listed goods shipped on
(Name of Carrier)
on consigned to
(Date)(Receiver or Consignee)
are the product(s) of the United States of America.
Marks and Numbers No. of Pkgs.
Boxes or
Weight (k)
Weight (k)
Full Description of Item
+ Row

State of

County of

Sworn to me

this day of 20

(Signature of Owner or Agent)

The , a recognized Chamber of Commerce under the laws of the State of , has examined the manufacturer's invoice or shipper's affidavit concerning the origin of the merchandize and, according to the best of its knowledge and belief, finds that the products named originated in the United States of North America.