BILL OF LADING

DELIVERY ORDER

Dale:1110112012

Addr6rs:5135 Park Rd, Spad 74

cry/siar/z p: Easl ch na, Ml 430s4
Conracii Sr Wahju. ngsih Chduvin

PM 0s:00

$"rp"d
Number:

Bill Of Lading / Booking

12-1 l -003-01 Chauvin

Nam. East china lviiislorag

Hours 02:00

?asetorl

PM

;:f:;Hn:,

Nam: EClc/o Salsoi CFS

Addressi 1331 West Torance B vd.
C lyTsraie/zip: Toftance, CA 90501
ConTact RECEIVING DEPARTMENT

llllilllillllllillilllilillillilltilliltililtiltililli

UPSFreight

730 560 574 DrR

roight Charc6 T6ms:

Mastar BilrOt Ladinq wilh attachod undorryns

Blls OrLadino

Nam: INTL MOVE C/O CAPITAT iRANSPORTATION SOLUTIONS

Add$: P.o.8oX441326

cirylsrar/zip: KENNESAW, GA 30160

REFERENCE BOOKING 15.878082 ON DELIVERY. SHIPPER REQUEST P/U ON NOVEI\4BER 1.2012 PLEASE CALL 30 MINUTES PRIOR TO
LIFE GATE REqURED AT PICKUP
NOTIFY BEFORE P]CKUP

coD Anounr $0.00

F66r6ms: corcr[ P,p.idE

qlyva|!6oflh.prop.dy.3iolow6:

Cuslomer cheok adcprabl:O

Not L abiriry L mrtation

for oss or dafr6a6

shipp.. signaru / Data

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in th 3 3h pmenl may b .pprlcab

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Loadd: F.eisht countd:

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KONSULAT JENOERAL REPUBLIK INDONESIA

TORONTO

SURAT PERNYATAAN MEMBAWA BARANG PINDAHAN

Saya yang bertanda tangan di bawah ini:
1. Nama lengkap (sesuai Paspor)

: SRI WAHJUNINGSIH CHAUVIN

2. Nomor Paspor Rl

: R 408306

3. Pekerjaan

: lbu rumah tangga

4. Alamat di Kanada

: 30127 St. Clair Parkway RR #4

Wallaceburg, ON N8A4L'1
Telp: 519 677 '1510
: Perumahan Puri Citra Rungkut Blok G No 5' JlAmir l\'Iahmud

5. Alamat di Indonesia

Kel. Gunung Anyar, Kec. Gunung Anyar

Surabaya 60294, Jawa Timur

Telp: 08123569271
(back for
Dengan ini menerangkan bahwa dalam perjalanan pulang ke lndonesia
barang-barang seperti terperinci di bawah ini:
No

Ivlerek & Nomor Seri

Jenis Baranq

goot

membawa serta

Jumlah

Lihat lampiran
tempelkan dengan lembar'ni)

irikman

akan dibawa pulang ke

seluruh barang tersebut dipergunakan selama saya berada di Kanada..dan
keterangan ini saya
keperluan prib;di serta tidak untuk diperjualbelikan Demikian surat
f"-O"""lii

""tri
sebenarnYa.
buat dengan

dibuat di : Toronto
Lhh dlhat |, ut dilcoslho6l dl Konsuhl J.ndaral
: 24 OKober 20'1 Ftatiuuk Indoneda dlToronto, Xanada i

tanggal

t'to

Tanda tangan,

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Indon66ia di ToEnto
bsrhnggung Jawab al63 Fl doxumsn. Kepah Pelw.Klan Rl

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