Page:United States Statutes at Large Volume 48 Part 2.djvu/265

FRIENDSHIP. ETC., TREATY-POLAND. JUNE 15,1931. 1537 [Enclosure 1] Forms. No. No. of the institution executing Certificate of oriIiD. h 'fi f" direct sblpments. t e cert! cate 0 orIgm. Certificate of origin I, (member or manager of the firm or corporation) _____________ _ (name of individual and title) export.er of the merchandise described below, do solemnly and truly declare that the said merchandise has been finished in the Iis the growth of I has been manufactured in United States of America, and that not less than 50 per cent 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: Port of shipment __________________________________________ _ On steamship _____________________________________________ _ (name of steamship) X ame of shipper ___________________________________________ _ (indicate whether merchant or manufacturer) Address of shipper _________________________________________ _ Consignee in Poland _______________________________________ _ (Indicate whether merchant or manufacturer) Address of consignee in Poland ______________________________ _ I>ated ___________________ _ Marks and Dumbers No. of packages or Description of the Weight Value cases commodities Groas Net ____________________ SignatureofExporter Subscribed and sworn to before me this __________ day of _____ _ •• ____________ 19 _________ _ ____________________ Notary Public CERTIFICA.TION BY CHA.MBER OF COMMERCE ____________________ 19____ a recognized chamber of commerce has examined the manufacturers invoice of shippers affidavit concerning the origin of the merchandise, and according to the best of its knowledge and belief, finds the prod- ucts named originated in the United States of America. (Signature and ~ of the Institution executlnc the Certi1l08te of OrIgiD) (Certification of competent Polish Consular Officer)