1.

Goods consigned from (Exporters business name, address, country)

CERTIFICATE OF ORIGIN
(NON PREFERENTIAL)
(Combined Declaration and Certificate)

Issued in India

MACCIA / MBI / /20

2. Goods consigned to (Consignees name, addess, country) ESTD. 1927

Apex Chamber of the State

Maharashtra Chamber of Commerce,

Industry and Agriculture
Oricon House, 6th Floor, 12, K. Dubhash Marg,
Fort, Mumbai - 400 001.
Tel. : Nos. 2285 5859 / 60 / 6739 5800 (30 Lines)
Fax : (022) 2285 5861
Email : maccia@maccia.org.in
3. Means of transport and route (as far as known) 4. For Official use

5. Item 6. Mark and 7. Number and kind of packages. 8. Origin 9. Gross weight 10. Number and
No. numbers of description of goods criteria or other date of invoices
packages quantity

11. Cer tification 12. Declaration by the expor ter

It is hereby cer tified / on the basic of control carried out, that the declaration by The undersigned hereby, declares that the above details
the exporter is correct. and statements are correct that all the goods were
produced and that they comply with the origin
requirements for expor ts to

Authorised Signatory
Maharashtra Chamber of Commerce, Industry and Agriculture Place date and signature of authorised signatory
Date : Mumbai, India