Page:United States Statutes at Large Volume 48 Part 2.djvu/270

 1542 FRIENDSHIP, ETC., TREATY-POLAND. JUNE 15, 1931. (Enclosure 21 Place and date CERTIFICATE OF ORIGIN. ~e(consignorofthegoods) -- (name of individual or of the ftnn) exporter(s) of the merchandise described below, do solemnly and lis the growth of I truly declare that the said merchandise has been finished in has been manufactured in the United States of America, and that not less than 50 percent of the total value of the goods represents the cost of labor and raw material in the United States, and that the said merchandise is correctly described as follows: Mara and numbers No. of packages or Description of com- ! Weight Value ____________~_~--,\m-OO--lti-esI--o-r-oqN-e-t-\- II I The above described merchandise is to be shipped per _________ _ (indicate whether on steamship (name) or by rallway) from ___ • _______________ _ (place of shipment) Consignee in the Polish custom territory ________________________ _ Address of consignee in the Polish custom territory _______________ _ Signature of consignor. Certification by the competent consular authority of the U.S .A. ~o. _____________________ _ (of the consular representative certUying the certUlcate of origin) _________ __________ _____ 19___ _ (Place and date) I do hereby certify, that I have examined the documents concerning the merchandise described above by the consignor, and according to my best knowledge and belief, I find the products named originated in the United States of America. Witness my hand and seal of office the day and year aforesaid. _____ _____ of the United States of America. (Certification by the competent Polish consular representative.)