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ORIGINAL 

1.Goods Consigned from (Exporter’s business name, address, country) Reference No. K011-20-0167694 

IONIA CO.,LTD. 

163-12 DODANG DONG, WONMI–GU, BUCHEON–SI, 

GYEONGGI–DO, KOREA 

TEL: 82-32-720-8042 

Reference Code. 09aa–dd23 

2.Goods Consigned to (Consignee’s name, address, country) 

|DLC VIỆT NAM 

|227 NGUYEN DINH CHINH, 11 WARD, PHU NHUAN 

DIST, HO CHI MINII, 

ATTN: NGUYEN THAI NANG (0973234357) VIETNAM 

KOREA–VIETNAM FREE TRADE AGREEMENT PREFERENTIAL TARIFF CERTIFICATE OF ORIGIN 

(Combined Declaration and Certificate) 

FORM KV 

THE REPUBLIC OF KOREA 

Issued in 

(Country) 

See Notes Overleaf 

3.Means of transport and route (as far as known) Departure date 

21 FEB, 2020 

Vessel’s name/Aircraft etc. KMTC PENANG 2002S 

Port of Discharge HO CHI MINH CITY, VIETNAM 

  1. Item 

number 

1 

  1. Marks and 

numbers on 

packages 

  1. For official use 

Preferential Treatment Given Under Korea–Viet Nam Free Trade Agreement 

Preferential Treatment Not Given (Please state reason/s) 

Signature of Authorized Signatory of the Importing Country 

  1. Number and type of packages, description of goods (including quantity where appropriate and HS code of the good in the importing country) 

[HS CODE: 8543.70] WATER IONIZER JP–107 

  1. Origin 

Criterion 

(See Overleaf 

Notes) 

CTC 

  1. Gross weight or other quantity and Value(FOB only when RVC criterion is used) 

410 EA 

  1. Number 

and date of 

Invoices 

ION200 109 

2020-01-09 

2 

[HS CODE 8421.99] FILTER FOR WATER PURIFIE 

CTC 

300 EA 

R 

NSF 

  1. Declaration by the exporter 

The undersigned hereby declares that the above details and statements are correct, that all goods were produced in 

THE REPUBLIC OF KOREA 

(Country) 

and that they comply with the origin requirements specified for these goods in the Korea–Viet Nam Free Trade Agreement for the goods exported to 

THE SOCIALIST REPUBLIC OF VIETNAM 

ing Country CO.,LTD. 

(Importing Country) 

from Rhee 

BUCHEON KOREA 04 MAR 2020 

Place and date, signature of authorized signatoryROK HEE, KWON 13. Remarks 

End Of Page 

  1. Certification 

It is hereby certified, on the basis of control carried out, that the declaration by the exporter is correct. 

BUCHEON 

04 MAR 2020 

CHAMBER OF 

THE BUCHEON! 

COMMERCE 

INDUSTRY 

ISSUED RETROACTIVELY 

Assistant Manager JANG–HYEONG LEE 

*부천상공회의소 

Place and date, signature and stamp of certifying authority 

Identify the authenticity of certificate for verification with the website. (http://cert.korcham.net/search) 

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