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RTIFICATE OF ORIGIN (Combined Declaration and Certificate) 2. Products consigned to (Consignee's name, address, FORM E country) Issued in (Country) See Overleaf Notes 3. Means of transport and route (as far as known) 4. For Official Use Departure date Preferential Treatment Given Vessel's name/Aircraft etc. Preferential Treatment Not Given (Please state reason/s) Port of Discharge .................................................................................. Signatu.

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