MINISTRY OF TRADE NURDIN ZULFIKAR SUSILAWATI REPUBLIC OF INDONESIA. Name of Official : Signature : II. II. A. III. III. A

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia Name of Issuing Authority

:

DINAS PERINDUSTRIAN PERDAGANGAN KOPERASI DAN UKM PROVINSI NANGGROE ACEH DARUSSALAM (PROVINCIAL OFFICE IN BANDA ACEH)

Address

:

Jl. Pocut Baren No.11 Kp. Mulia, Banda Aceh NANGGROE ACEH DARUSSALAM

Phone No.

:

(0651) 32429

Fax

:

(0651) 32428

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

NURDIN

II.

II. A.

ZULFIKAR

III.

III. A.

SUSILAWATI

IV.

SEAL

1


:

DINAS PERINDUSTRIAN DAN PERDAGANGAN KABUPATEN ACEH UTARA (DISTRICT OFFICE IN LHOKSEUMAWE)

Address

:

Jl. Teungku Chik Ditiro No. 1 Lhokseumawe 24351 NANGGROE ACEH DARUSSALAM

Phone No.

:

+62 645 42305

Fax

:

+62 645 43048

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

ARIFIN

II.

II. A.

FADHLI

III.

III. A.

MUZAKKAR

IV.

SEAL

2


:

MANAGEMENT BOARD OF SABANG FREE PORT & TRADE ZONE

Address

:

Jl. T. Panglima Polem Sabang Indonesia

Phone No.

:

+62 0652 22144

Fax

:

+62 0652 22143

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

MUHAMMAD

II.

II. A.

AGUS SALIM

III.

III. A.

WARDIANA

IV.

SEAL

3

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia

Name of Issuing Authority

:

DINAS PERINDUSTRIAN DAN PERDAGANGAN PROVINSI SUMATERA UTARA (PROVINCIAL OFFICE IN MEDAN)

Address

:

Jl Putri Hijau No. 6 Medan 20001 Kotak Pos 1545-1196 SUMATERA UTARA

Phone No.

:

[061] 4515029, 4514648, 4525655, 4522471, 4142171, 4149903, 4525566, 4515060.

Fax

:

[061] 4525655, 4150067, 4521130

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

BIDAR ALAMSYAH

II.

II. A.

SUJATMIKO III.

III. A.

FITRA KURNIA IV. EFENDI MANURUNG

IV.

SEAL

4



: LEMBAGA TEMBAKAU MEDAN

Address

: Jl. STM No. 17 Kampung Baru Medan, SUMATERA

Phone No.

: (061) 7862040

Fax

: (061) 786204

E-mail

: -

(TOBACCO INSTITUTION IN MEDAN) UTARA

Name of Official :

Signature :

I

I. A.

HERIZAL ANANDA PULUNGAN

II.

II. A.

NOVIRA DWI SHANTI ARTSIWI

III.

III. A.

ALI IMRAN

IV.

SEAL

5

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia DINAS PERINDUSTRIAN DAN PERDAGANGAN


: PROVINSI SUMATERA BARAT

Address

: Jl. Aur No. 1 Padang 25113 SUMATERA BARAT

Phone No.

: +62 751 22866

Fax

: +62 751 22866

E-mail

: -

(PROVINCIAL OFFICE IN PADANG)

Name of Official :

Signature :

I

I. A.

SYAFRUDDIN

II.

II. A.

TRIYANI SUSILOWATI

III.

III. A.

DEFITRA

IV.

SEAL

6



: PROVINSI RIAU

Address

:

Phone No.

: (0761) 21900, 22900

Fax

: (0761) 28066

E-mail

: -

(PROVINCIAL OFFICE IN PEKANBARU) Gedung Menara Lancang Kuning Lt.5 Jl. Jend. Sudirman No. 460 Pekanbaru, RIAU

Name of Official :

Signature :

I

I. A.

NIZHAMUL

II.

II. A.

AGUNG P.MANDAHU

III.

III. A.

YUSMI AKHSEN

IV.

IV.

EMMY LINCE RUSMIATI

IV.

SEAL

7



: KABUPATEN INDRAGIRI HILIR

Address

: Jl. Veteran No. 02 - Tembilahan - RIAU

Phone No.

: (0768) 21045, 21047

Fax

: (0768) 21047

E-mail

: -

(DISTRICT OFFICE IN TEMBILAHAN)

Name of Official :

Signature :

I

I. A.

PAHROLROZY

II.

II. A.

RAJA TERUNA

III.

III. A.

BUDDY SASTRA

IV.

SEAL

8

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia DINAS KOPERASI UKM, PERINDUSTRIAN DAN


: PERDAGANGAN KABUPATEN BINTAN

Address

:

Phone No.

: (0771) 21357

Fax

: (0771) 311979

E-mail

: -

(DISTRICT OFFICE IN TANJUNG PINANG) Jl. M.T. Haryono Km. 3,5 No. 46 Tanjungpinang 29122 PROVINSI KEPULAUAN RIAU

Name of Official :

Signature :

I

I. A.

EDI PRIBADI

II.

II. A.

MISWAR

III.

III. A.

TUT WURI HANDAYANI

IV.

SEAL

9

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia DINAS PERINDUSTRIAN, PERDAGANGAN DAN


: KOPERASI KOTA DUMAI

Address

: Jl. Sultan Syarif Kasim No. 16 Dumai, RIAU

Phone No.

: (0765) 35760

Fax

: (0765) 439750

E-mail

: [email protected]

(MUNICIPALITY OFFICE IN DUMAI)

Name of Official :

Signature :

I

I. A.

ZULKARNAEN

II.

II. A.

KAMARUDDIN

III.

III. A.

RIDWAN GULTOM

IV.

SEAL

10

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia DINAS PERINDUSTRIAN, PERDAGANGAN ENERGI


: DAN SUMBER DAYA MINERAL KOTA BATAM

Address

:

Phone No.

: (0778) 466742

Fax

: (0778) 466703

E-mail

: [email protected]

(MUNICIPALITY OFFICE IN BATAM)

Jl. Engku Putri No. 17, Gedung Bersama Pemko Batam Lt. 5, Batam 29464

Name of Official :

Signature :

I

I. A.

AMSAKAR ACHMAD

II.

II. A.

YUHERMON III.

III. A.

LENY NURISKAWATY

IV.

IV.

ZUL AMRI

IV.

SEAL

11

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia BADAN PENGUSAHAAN BATAM


:

Address

: BIDA ANNEX II BATAM ISLAND

Phone No.

: 0778 - 462047 / 462048

Fax

: 0778 - 462240 / 462246

E-mail

: [email protected]

(BATAM INDONESIA FREE ZONE AUTHORITY)

Name of Official :

Signature :

I

I. A.

FATHULLAH

II.

II. A.

BARLIAN UNTORO

III.

III. A.

RUSTIKOWATI

IV.

SEAL

12



: PROVINSI JAMBI

Address

:

Phone No.

: (0741) 65529, 64507

Fax

: (0741) 62627

E-mail

: [email protected]

(PROVINCIAL OFFICE IN JAMBI) Jl. Letjen. Suprapto No. 28 Telanaipura JAMBI

Name of Official :

Signature :

I

I. A.

ABDUL ZAKI

II.

II. A.

M. YAMIN

III.

III. A.

FATIMAH

IV.

SEAL

13



: PROVINSI SUMATERA SELATAN

Address

:

Phone No.

: (0711) 310447, 352072, 351449,350408, 350302

Fax

: (0711) 310447, 350408, 350302

E-mail

: [email protected]

(PROVINCIAL OFFICE IN PALEMBANG) Jl. Kapten A. Rivai No. 408 Palembang 30136, SUMATERA SELATAN

Name of Official :

Signature :

I

I. A.

PERMANA

II.

II. A.

ACHMAD MIRZA III.

III. A.

CHALID

IV.

SEAL

14

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia DINAS KOPERASI USAHA KECIL MENENGAH PERINDUSTRIAN DAN PERDAGANGAN PROVINSI BENGKULU (PROVINCIAL OFFICE IN BENGKULU)


:

Address

: Jl. S. Parman No. 21 Bengkulu 38227, BENGKULU

Phone No.

: (0736) 21275, 21287, 342875

Fax

: (0736) 26272, 342875

E-mail

: [email protected]

Name of Official :

Signature :

I

I. A.

ALI MUSRAMIN

II.

II. A.

NOPTI SURYADI

III.

III. A.

MINARNI

IV.

SEAL

15

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia DINAS KOPERASI, UMKM, PERINDUSTRIAN DAN


: PERDAGANGAN PROVINSI LAMPUNG

Address

: Jl. Cut Mutia No. 23 B BANDAR LAMPUNG

Phone No.

: (0721) 487310, 487311, 482512, 482612

Fax

: (0721) 481440

E-mail

: [email protected]

(PROVINCIAL OFFICE IN BANDAR LAMPUNG)

Name of Official :

Signature :

I.

I. A.

CHOIRIA PANDARITA

II.

II. A.

RATNA DEWI UMAR

III.

III. A.

MARYANI

IV.

TEGUH WINARNO

IV.

SEAL

16

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia DINAS KOPERASI, USAHA MIKRO, KECIL DAN MENENGAH DAN PERDAGANGAN PROVINSI DKI JAKARTA (PROVINCIAL OFFICE IN JAKARTA)


:

Address

: JAKARTA

Phone No.

: (62-21) 45848012

Fax

: (62-21) 45848011, 45848014

E-mail

: [email protected]

Jl. Perintis Kemerdekaan / BGR I No. 3 Jakarta Utara,

Name of Official :

Signature :

I

I. A.

JOKO KUNDARYO

II.

II. A.

TATI BUDIARTI

III.

III. A.

IRWANDI

IV.

IV. A.

LUHUTMA PARULIAN HUTABARAT

IV.

SEAL

17


SUKU DINAS KOPERASI, USAHA MIKRO, KECIL DAN MENENGAH DAN PERDAGANGAN


:

Address

:

Jl. Prapanca Raya No. 9 Blok C Lt. 7 Kebayoran Baru, JAKARTA SELATAN

Phone No.

:

(021) 72798222

Fax

:

(021) 7261732

E-mail

:

[email protected]

KOTA ADMINISTRASI JAKARTA SELATAN (MUNICIPALITY OFFICE IN KEBAYORAN BARU)

Name of Official :

Signature :

I

I. A.

NURJANAH

II.

II. A.

SUTAN SORIALAM

III.

III. A.

SYAMSURI

IV.

SEAL

18

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia SUKU DINAS KOPERASI, USAHA MIKRO, KECIL DAN MENENGAH DAN PERDAGANGAN


:

Address

:

Jl. Dr. Sumarno Kode Pos 13950 Gedung Blok B2 Lt. 3 Jakarta Timur, JAKARTA

Phone No.

:

(021) 48702168

Fax

:

(021) 48700854

E-mail

:

[email protected]

KOTA ADMINISTRASI JAKARTA TIMUR (MUNICIPALITY OFFICE IN CAKUNG)

Name of Official :

Signature :

I

I. A.

ALBERTUS MIKAEL SIREGAR

II.

II. A.

NEFI ANTO DALISWANTORO

III.

III. A.

MULYATI

IV.

SEAL

19



:

Address

:

Jl. Tanah Abang I No. 1 Kantor Walikota Jakarta Pusat 11060, JAKARTA

Phone No.

:

(021) 3805491

Fax

:

(021) 3805491

E-mail

:

[email protected]

KOTA ADMINISTRASI JAKARTA PUSAT (MUNICIPALITY OFFICE IN TANAH ABANG)

Name of Official :

Signature :

I

I. A.

SRI INDRASTUTI

II.

II. A.

UDI

III.

III. A.

SYAMSU RIZAL

IV.

SEAL

20



:

Address

:

Jl. Raya Kembangan No. 2 Blok B Lt. V Jakarta Barat, JAKARTA

Phone No.

:

021 – 5823369 Ext. 6866

Fax

:

021 - 58356232

E-mail

:

[email protected]

KOTA ADMINISTRASI JAKARTA BARAT (MUNICIPALITY OFFICE IN PURI KEMBANGAN)

Name of Official :

Signature :

I

I. A.

SLAMET WIDODO

II.

II. A.

TRININGSIH

III.

III. A.

TAUFIK HELMY

IV.

SEAL

21

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia SUKU DINAS KOPERASI, USAHA MIKRO KECIL DAN MENENGAH DAN PERDAGANGAN


:

Address

:

Jl. Perintis Kemerdekaan/BGR I No. 2 Jakarta Utara 14240

Phone No.

:

(021) 45848008

Fax

:

(021) 45848008

E-mail

:

[email protected]

KOTA ADMINISTRASI JAKARTA UTARA (MUNICIPALITY OFFICE IN TANJUNG PRIOK)

Name of Official :

Signature :

I

I. A.

ALMON DANIEL

II.

II. A.

ACHMAD HUSEIN PELU

III.

III. A.

MURTI RAHAYU

IV.

SEAL

22



:

PT. KAWASAN BERIKAT NUSANTARA (PERSERO) SBU KAWASAN CAKUNG (NUSANTARA BONDED ZONE IN CAKUNG)

Address

:

Jl. Raya Cakung Cilincing-Tg.Priok Jakarta 14140

Phone No.

:

021) 44820909 ext. 1501

Fax

:

(021) 44820068

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

SUDIRO AGUNG DANANTO

II.

II. A.

IRWANDI

III.

III. A.

ROSNANI SYARIEF

IV.

SEAL

23



:

PT. (PERSERO) KAWASAN BERIKAT NUSANTARA UNIT USAHA TANJUNG PRIOK (NUSANTARA BONDED ZONE IN TANJUNG PRIOK)

Address

:

Jl. Pelabuhan Nusantara Tanjung Priok, JAKARTA 14130

Phone No.

:

(021) 4301183

Fax

:

(021) 53930513

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

M. SITOHANG

II.

II. A.

NURIL RACHMAT

III.

III. A.

SUNARYA

IV.

SEAL

24



:

PT. KAWASAN BERIKAT NUSANTARA (PERSERO) SBU KAWASAN MARUNDA (NUSANTARA BONDED ZONE IN MARUNDA)

Address

:

Jl. Lampung No. 1 Cilincing Jakarta Utara 14120, JAKARTA

Phone No.

:

(021) 44851525-9

Fax

:

(021) 44851434, 44851431

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

SUDIRO AGUNG DANANTO

II.

II. A.

SENTOT YOGA TAMTOMO

III.

III. A.

AAN RUSTANDI

IV.

SEAL

25



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN PROVINSI JAWA BARAT (PROVINCIAL OFFICE IN BANDUNG)

Address

:

Jl. Asia Afrika No. 146 Bandung 40261, JAWA BARAT

Phone No.

:

(022) 4230897 – 4230898

Fax

:

(022) 4200331 – 4230929

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

FERRY SOFWAN ARIF II.

II. A.

BISMARK

III.

III. A.

LINA SJAM

IV.

IV. A.

PUJI ASTUTI

IV.

SEAL

26



:

DINAS KOPERASI UKM PERINDUSTRIAN DAN PERDAGANGAN KABUPATEN BOGOR (DISTRICT OFFICE IN CIBINONG)

Address

:

Jl. Aman Komplek Perkantoran Pemkab Bogor, Cibinong 16914 Bogor, Jawa BARAT

Phone No.

:

(021) 8755008, 8755947, 87903509, 87903917, 8764351

Fax

:

(021) 8755947

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

UDIN SYAMSUDIN

II.

II. A.

AAN SURYA PRIYANA

III.

III. A.

JONA SIJABAT

IV.

SEAL

27



:

DINAS KOPERASI PERINDUSTRIAN DAN PERDAGANGAN KABUPATEN SUKABUMI (DISTRICT OFFICE IN SUKABUMI)

Address

:

Jl. Raya Cibolang km 7 No. 33 Sukabumi JAWA BARAT

Phone No.

:

(0266) 222698

Fax

:

(0266) 222698

E-mail

:

-

Name of Official :

Signature :

I

I. A.

ASEP JAPAR

II.

II. A.

ELA NURLAELA

III.

III. A.

VICTOR DOLLAR PARDOMUAN

IV.

SEAL

28



:

DINAS KOPERASI, UKM, PERINDUSTRIAN DAN PERDAGANGAN KABUPATEN BANDUNG (DISTRICT OFFICE IN SOREANG)

Address

:

Jl. Raya Soreang Km 17 Komp. Pemda Kabupaten Bandung, JAWA BARAT

Phone No.

:

(022) 5894558

Fax

:

(022) 5894558

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

POPI HOPIPAH

II.

II. A.

ENGKUS

III.

III. A.

HARRY GUMILAR

IV.

SEAL

29



:

DINAS KOPERASI PERINDUSTRIAAN DAN PERDAGANGAN KABUPATEN TASIKMALAYA (DISTRICT OFFICE IN TASIKMALAYA)

Address

:

Jl. Pemuda No. 2 Tasikmalaya, JAWA BARAT

Phone No.

:

(0265) 330917

Fax

:

(0265) 3309172

E-mail

:

-

Name of Official :

Signature :

I

I. A.

SAFARI AGUSTIN

II.

II. A.

NIA JUNIARTI

III.

III. A.

CACA SUGANDI

IV.

SEAL

30



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN KABUPATEN CIREBON (DISTRICT OFFICE IN SUMBER)

Address

:

Jl. Sunan Kalijaga No. 10 Sumber 45611, JAWA BARAT

Phone No.

:

(0231) 321495 321073

Fax

:

(0231) 321073

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

HAKI

II.

II. A.

EKA SUKAWATI

III.

III. A.

SUND DEWI

IV.

SEAL

31



:

DINAS KOPERASI, UMKM, PERINDUSTRIAN DAN PERDAGANGAN KABUPATEN PURWAKARTA (DISTRICT OFFICE IN PURWAKARTA)

Address

:

JL. Jendral Ahmad Yani No. 170 Puwakarta 41113 JAWA BARAT

Phone No.

:

(0264) 201064

Fax

:

(0264) 204038

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

DEDDY EFFENDI

II.

II. A.

FATA FARIDUL HISAN

III.

III. A.

ACHMAD GUNAWAN

IV.

SEAL

32

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia DINAS PERINDUSTRIAN, PERDAGANGAN, PERTAMBANGAN DAN ENERGI


:

Address

:

Jl. Ahmad Yani No. 30, Karawang 41315

Phone No.

:

(0267) 402781

Fax

:

(0267) 409984

E-mail

:

-

KABUPATEN KARAWANG (DISTRICT OFFICE IN KARAWANG)

Name of Official :

Signature :

I

I. A.

HANAFI

II.

II. A.

ENDANG HERMAWAN

III.

III. A.

DELFIRA

IV.

SEAL

33



:

DINAS PERINDUSTRIAN PERDAGANGAN KOPERASI DAN USAHA MIKRO KECIL MENENGAH KABUPATEN BEKASI (DISTRICT OFFICE IN BEKASI)

Address

:

Komp. Perkantoran Pemda Kabupaten Bekasi Desa Sukamahi Kecamatan Cikarang Pusat Bekasi, JAWA BARAT

Phone No.

:

(021) 89970562/89970563

Fax

:

(021) 89970562

E-mail

:

-

Name of Official :

Signature :

I

I. A.

TITOT SUHERYANTO

II.

II. A.

NURAHMAN

III.

III. A.

AGUS FARIZ

BURHAN

IV.

AHMAD

SEAL

34



:

DINAS KOPERASI, PERINDUSTRIAN DAN PERDAGANGAN KOTA SUKABUMI (MUNICIPALITY OFFICE IN SUKABUMI)

Address

:

Jl. Suryakencana No. 78 Sukabumi, JAWA BARAT

Phone No.

:

(0266) 221954

Fax

:

(0266) 6248105

E-mail

:

-

Name of Official :

Signature :

I

I. A.

DUDI FATHUL JAWAD

II.

II. A.

R.W. DHARMAWAN S.

III.

III. A.

LINDRI PRAGIWATI

IV.

SEAL

35



:

DINAS KOPERASI, USAHA KECIL DAN MENENGAH PERINDUSTRIAN DAN PERDAGANGAN KOTA BANDUNG (MUNICIPALITY OFFICE IN BANDUNG)

Address

:

Jl. Kawaluyaan No. 2 Kota Bandung, JAWA BARAT

Phone No.

:

(022) 7308358

Fax

:

(022) 7308358

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

EMA SUMARNA

II.

II. A.

ASEP SUDRAJAT

III.

III. A.

INDAH KURNIAWATI

IV.

SEAL

36



:

DINAS PERINDUSTRIAN, PERDAGANGAN DAN KOPERASI UMKM KOTA CIREBON (MUNICIPALITY OFFICE IN CIREBON)

Address

:

Jl. Dr. Cipto Mangunkusumo No. 20 KOTA Cirebon Jawa Barat – Indonesia

Phone No.

:

(0231) 3383979

Fax

:

(0231) 209155

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

YATI ROHAYATI

II.

II. A.

HERI HARYANTO

III.

III. A.

NYI RADEN TERIN METERINA

IV.

SEAL

37



:

DINAS PERINDUSTRIAN PERDAGANGAN DAN KOPERASI KOTA BEKASI (MUNICIPALITY OFFICE IN BEKASI)

Address

:

Jl. Rawa Tembaga I No. 1 Bekasi, JAWA BARAT

Phone No.

:

(021) 8842009

Fax

:

(021) 8842829

E-mail

:

-

Name of Official :

Signature :

I

I. A.

NOVIAR HERMANSYAH

II.

II. A.

KARTO

III.

III. A.

RAHMAT MULYADI

IV.

SEAL

38



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN PROVINSI JAWA TENGAH (PROVINCIAL OFFICE IN SEMARANG)

Address

:

Jl. Pahlawan No. 4 Semarang 50241, JAWA TENGAH

Phone No.

:

024 - 8311708, 8311710

Fax

:

024 - 8311707, 8311710

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

P. EDISON AMBARURA

II.

II. A.

RATIH SUSYATI S

III.

III. A.

ENDANG SETIYANI IV.

IV. A.

MARIA SULISTYOWATI

IV.

SEAL

39



:

DINAS PERINDUSTRIAN, PERDAGANGAN, KOPERASI DAN UMKM KABUPATEN CILACAP (DISTRICT OFFICE IN CILACAP)

Address

:

Jl. M.T. Haryono No. 159 Cilacap, JAWA TENGAH

Phone No.

:

(0282) 545017

Fax

:

(0282) 545017

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

DIAN ARINDA MURNI

II.

II. A.

BAMBANG TUTUKO

III.

III. A.

TOTO IV.

IV. A.

BUANG SURIPTO

IV.

SEAL

40



:

DINAS PERINDUSTRIAAN DAN PERDAGANGAN KOTA SURAKARTA (MUNICIPALITY OFFICE IN SURAKARTA)

Address

:

Jl. Yosodiputro 164 Surakarta 57139, JAWA TENGAH

Phone No.

:

[0271] 714942 ,712022

Fax

:

[0271] 719932

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

ROHANAH

II.

II. A.

DJOKO SULISTYO

III.

III. A.

SRI REDJEKI S K IV.

IV. A.

ENDANG KURNIA MAHARANI

IV.

SEAL

41



:

LEMBAGA TEMBAKAU SURAKARTA (TOBACCO INSTITUTION IN SURAKARTA)

Address

:

Jl. Pajang Kartasura, Km. 8 Pabelan 219/57101 Surakarta JAWA TENGAH

Phone No.

:

(0271) 743959

Fax

:

(0271) 743959

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

EDI WAHYUONO

II.

II. A.

SENEN

III.

III. A.

ANIK SOFIAH

IV.

SEAL

42



:

DINAS PERINDUSTRIAN PERDAGANGAN KOPERASI DAN UKM PROVINSI D.I. YOGYAKARTA (PROVINCIAL OFFICE IN YOGYAKARTA)

Address

:

Jl. Kusumanegara 133 Yogyakarta 55165, D.I YOGYAKARTA

Phone No.

:

(0274) 514207

Fax

:

(0274) 512437

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

RIYADI IBSS

II.

II. A.

RAHAYU SRI LESTARI

III.

III. A.

FIRSANEDI

IV.

SEAL

43



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN PROVINSI JAWA TIMUR (PROVINCIAL OFFICE IN SURABAYA)

Address

:

Jl. Siwalan Kerto Utara II/No. 42 Surabaya 60236, JAWA TIMUR

Phone No.

:

(031) 8432417, 8499895,8432373 ext. 204

Fax

:

(031) 8432417, 8432373

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

BUDI SETIAWAN

II.

II. A.

LIRI LESTARI

III.

III. A.

HENRI FERDINAND SAHULATA

IV.

SEAL

44



:

DINAS PERINDUSTRIAN, PERDAGANGAN DAN KOPERASI KABUPATEN BANYUWANGI (DISTRICT OFFICE IN BANYUWANGI)

Address

:

Jl. Adi Sucipto No. 76, Banyuwangi JAWA TIMUR

Phone No.

:

(0333) 421320

Fax

:

(0333) 427002

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

ALI RUCHI

II.

II. A.

GELLA RUSMANINGRUM

III.

III. A.

BUDI UTOMO

IV.

SEAL

45



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN KABUPATEN PASURUAN (DISTRICT OFFICE IN PASURUAN)

Address

:

Jl. Veteran No. 5 Pasuruan 67125, JAWA TIMUR

Phone No.

:

(0343) 424009

Fax

:

(0343) 417911

E-mail

:

-

Name of Official :

Signature :

I

I. A.

ZAINAL MUSYARIF

II.

II. A.

ZAINUDDIN

III.

III. A.

DAYA UJI

IV.

SEAL

46

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia DINAS KOPERASI USAHA KECIL MENENGAH PERINDUSTRIAN DAN PERDAGANGAN KABUPATEN GRESIK (DISTRICT OFFICE IN GRESIK) Jl. Dr. Wahidin Sudirohusodo No. 245, Gresik, JAWA TIMUR


:

Address

:

Phone No.

:

(031) 3956708, 3956709

Fax

:

(031) 3956710

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

MOKHAMMAD NAJIKH

II.

II. A.

DJIKIN ISNOMO

III.

III. A.

SARBINI

IV.

SEAL

47

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia UNIT PELAKSANA TEKNIS PENGUJIAN SERTIFIKASI MUTU BARANG - LEMBAGA TEMBAKAU JEMBER


:

Address

:

Jl. Kalimantan No. 1 Jember 68121, JAWA TIMUR

Phone No.

:

+62331338396

Fax

:

+62331334825

E-mail

:

[email protected]

(REGIONAL LABORATORY FOR TESTING AND CONTROL - TOBACCO INSTITUTION IN JEMBER)

Name of Official :

Signature :

I

I. A.

QUALITY

DESAK NYOMAN SIKSIAWATI

II.

II. A.

SETIANTO

III.

III. A.

DEWAN HERTANTO

IV.

SEAL

48


UNIT PELAKSANA TEKNIS PENGUJIAN SERTIFIKASI MUTU BARANG DAN LEMBAGA TEMBAKAU SURABAYA


:

Address

:

Jl. Gayung Kebonsari Dalam No. 12A, Surabaya 60235, JAWA TIMUR

Phone No.

:

(031) 8280762,8280753

Fax

:

(031) 8294291

E-mail

:

[email protected]

(REGIONAL LABORATORIES FOR TESTING AND QUALITY CERTTIFICATION AND TOBACCO INSTITUTION IN SURABAYA)

Name of Official :

Signature :

I

I. A.

LILIEK ANGGREINI

II.

II. A.

RIRIN AFRIANDARI

III.

III. A.

ICHSANUDIN MA’DJID IV.

IV. A.

ABDIEL POPANG KABANGA

IV.

SEAL

49



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN PROVINSI KALIMANTAN BARAT (PROVINCIAL OFFICE IN PONTIANAK)

Address

:

Jl. Sultan Syahrir No.2 Pontianak 78116, KALIMANTAN BARAT

Phone No.

:

0561 – 732151 / 732610

Fax

:

0561 – 734229

E-mail

:

Name of Official :

Signature :

I

I. A.

ROBERTUS ISDIUS

II.

II. A.

SUGIRI

III.

III. A.

EKO DARMAWANSYAH

IV.

SEAL

50



:

DINAS PERNDUSTRIAN DAN PERDAGANGAN PROVINSI KALIMANTAN TENGAH (PROVINCIAL OFFICE IN PALANGKARAYA)

Address

:

Jl. Yos Sudarso No. 1 Palangkaraya 73112, KALIMANTAN TENGAH

Phone No.

:

(0536) 3220012

Fax

:

(0536) 3220012

E-mail

:

-

Name of Official :

Signature :

I

I. A.

MUCHTAR

II.

II. A.

TONI JHON SIANO

III.

III. A.

HORAS SINAGA

IV.

SEAL

51



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN KABUPATEN KOTAWARINGIN BARAT (DISTRICT OFFICE IN PANGKALAN BUN)

Address

:

Jl. Sutan Syahrir No. 10 Pangkalan Bun, KALIMANTAN TENGAH

Phone No.

:

(0532) 21064

Fax

:

(0532) 21064, 21422

E-mail

:

-

Name of Official :

Signature :

I

I. A.

JAHOTLER LUMBAN GAOL

II.

II. A.

GOZALI

III.

III. A.

-

IV.

SEAL

52



:

DINAS PERINDUSTRIAN, PERDAGANGAN DAN PASAR KABUPATEN KOTAWARINGIN TIMUR (DISTRICT OFFICE IN SAMPIT)

Address

:

Jl. Jend. Sudirman Km. 6,7 – Sampit. KALIMANTAN TENGAH 74322

Phone No.

:

(0531) 21188

Fax

:

(0531) 21188

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

MUDJIONO

II.

II. A.

RIHARD SIREGAR

III.

III. A.

-

IV.

SEAL

53

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia DINAS PERINDUSTRIAN PERDAGANGAN KOPERASI USAHA MIKRO KECIL DAN MENENGAH


:

Address

:

Jl. Tambun Bungai No. 7 Kuala Kapuas, KALIMANTAN TENGAH

Phone No.

:

(0513) 22013, 21081, 21076

Fax

:

(0513) 24300

E-mail

:

[email protected]

KABUPATEN KAPUAS (DISTRICT OFFICE IN KUALA KAPUAS)

Name of Official :

Signature :

I

I. A.

TERAS D SUHIN

II.

II. A.

BAHRUDIN

III.

III. A.

JEMIE IV.

IV. A.

RAHAYU TRIS GIPIYANTO IV.

SEAL

54



:

DINAS PERINDUSTRIAN PERDAGANGAN KOPERASI DAN UMKM PROVINSI KALIMANTAN TIMUR (PROVINCIAL OFFICE IN SAMARINDA)

Address

:

Jl. Basuki Rahmat No. 55 Samarinda 75117, KALIMANTAN TIMUR

Phone No.

:

(0541) 747161/742482

Fax

:

(0541) 742495

E-mail

:

[email protected]; www.indagkop-kaltim.go.id

Name of Official :

Signature :

I

I. A.

MOHAMMAD DJAILANI

II.

II. A.

ELFINA

III.

III. A.

M. YUSUF PEBRYANDI

IV.

SEAL

55



:

DINAS KOPERASI, PERINDUSTRIAN DAN PERDAGANGAN KABUPATEN BERAU (DISTRICT OFFICE IN TANJUNG REDEP)

Address

:

Jl. Dr. Murjani I No. 93 Tanjung Redep – Berau 77311, KALIMANTAN TIMUR

Phone No.

:

(0554) 21026

Fax

:

(0554) 2027784

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

MANSYAH KELANA

II.

II. A.

JAKA SISWANTA

III.

III. A.

IDA JULIAH

IV.

SEAL

56



:

DINAS PERINDUSTRIAN, PERDAGANGAN, KOPERASI DAN USAHA MIKRO, KECIL DAN MENENGAH KOTA BONTANG (MUNICIPALITY OFFICE IN BONTANG)

Address

:

Jl. M.H. Thamrin No. 42 Bontang 76311, KALIMANTAN TIMUR

Phone No.

:

(0548) 22912

Fax

:

(0548) 3036358

E-mail

:

-

Name of Official :

Signature :

I

I. A.

RIZA PAHLEVI

II.

II. A.

SRI REDJEKI

III.

III. A.

AHMAD YADI

IV.

SEAL

57



:

DINAS PERINDUSTRIAN, PERDAGANGAN DAN KOPERASI KOTA BALIKPAPAN (MUNICIPALITY OFFICE IN BALIKPAPAN)

Address

:

Jl. Tanjung Pura I No. 72 Balikpapan, KALIMANTAN TIMUR

Phone No.

:

[0542] 731210, 422420, 422160.

Fax

:

[0542] 731210

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

DOORTJE MARPAUNG

II.

II. A.

SAID ACHSIN

III.

III. A.

HERY SUDIANTO

IV.

SEAL

58



:

DINAS PERINDUSTRIAN, PERDAGANGAN DAN KOPERASI KOTA TARAKAN (MUNICIPALITY OFFICE IN TARAKAN)

Address

:

Jl. Jend. Sudirman RT.03 No.03 Kota Tarakan 77111, KALIMANTAN TIMUR

Phone No.

:

(0551) 21660

Fax

:

(0551) 25289

E-mail

:

-

Name of Official :

Signature :

I

I. A.

SUBONO

II.

II. A.

UNTUNG PRAYITNO

III.

III. A.

MISRAN

IV.

SEAL

59

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia DINAS PERINDUSTRIAN DAN PERDAGANGAN PROVINSI KALIMANTAN SELATAN (PROVINCIAL OFFICE IN BANJARMASIN)


:

Address

:

Phone No.

:

(0511) 3352536-3354219-3352495-3354294-33527123354213-3352536

Fax

:

(0511) 3352536, 3354219

E-mail

:

[email protected]

Jl. D.I. Panjaitan No. 41 Banjarmasin KALIMANTAN SELATAN

Name of Official :

Signature :

I

I. A.

FARIDA WARIANSI

II.

II. A.

GUSTI YASNI IQBAL III.

III. A.

NURFUANSYAH IV.

IV. A.

HELAUNIATY

IV.

SEAL

60

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia DINAS KOPERASI, UKM, PERINDUSTRIAN DAN PERDAGANGAN KABUPATEN KOTABARU (DISTRICT OFFICE IN KOTABARU)


:

Address

:

Phone No.

:

+62 0518 21177

Fax

:

+62 0518 21177

E-mail

:

[email protected]

Jl. Kenanga No. 2 Kotabaru 72116 KALIMANTAN SELATAN

Name of Official :

Signature :

I

I. A.

ZAINAL ARIFIN

II.

II. A.

AHMAD KUSAIRIN

III.

III. A.

ERLINA MARTAYANI IV.

IV. A.

FRANS SUBAKTI

IV.

SEAL

61



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN PROVINSI BALI (PROVINCIAL OFFICE IN DENPASAR)

Address

:

Jl. Raya Puputan Komplek Niti Mandala, Denpasar 80235, BALI

Phone No.

:

(0361) 223096

Fax

:

(0361) 223095

E-mail

:

[email protected];[email protected]

Name of Official :

Signature :

I

I. A.

NI WAYAN KUSUMAWATHI

II.

II. A.

I MADE SWASTIKA

III.

III. A.

PUTU BAGIADA

IV.

SEAL

62



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN KABUPATEN GIANYAR (DISTRICT OFFICE IN GIANYAR)

Address

:

Jl. Erlangga (Komplek Civic Centre), Gianyar 80511, BALI

Phone No.

:

(0361) 943105

Fax

:

(0361) 948968

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

WAYAN SUAMBA

II.

II. A.

I WAYAN SURANADI

III.

III. A.

ANAK AGUNG GDE WISNU

IV.

SEAL

63



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN PROVINSI NUSA TENGGARA BARAT (PROVINCIAL OFFICE IN MATARAM)

Address

:

Jl. Langko No. 61 Mataram 83125, NUSA TENGGARA BARAT

Phone No.

:

[0370] 633736, 631247, 623290, 633166

Fax

:

[0370] 633736

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

BAIQ NOVIANA INDIARI

II.

II. A.

MOH. HAMKA

III.

III. A.

RATNANINGSIH

IV.

SEAL

64



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN PROVINSI SULAWESI SELATAN (PROVINCIAL OFFICE IN MAKASSAR)

Address

:

Jl. Ujung Pandang No. 3 Makassar, SULAWESI SELATAN

Phone No.

:

(0411)323535, 324315, 323727, 324257

Fax

:

(0411) 324367

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

AMAR KADIR

II.

II. A.

ACHMAD HABIB

III.

III. A.

MUNARTI

IV.

SEAL

65



:

DINAS KOPERASI, UMKM, PERINDUSTRIAN DAN PERDAGANGAN PROVINSI SULAWESI TENGAH (PROVINCIAL OFFICE IN PALU)

Address

:

Jl. R.A Kartini NO. 17 Palu 94112 ,

Phone No.

:

(0451) 425265, 428503, 411289

Fax

:

(0451) 454564, 421200, 426359

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

ABUBAKAR ALMAHDALI

II.

II. A.

TONNY AK MUHAMAD

III.

III. A.

ABDUL MUIN

IV.

SEAL

66



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN PROVINSI SULAWESI UTARA (PROVINCIAL OFFICE IN MANADO)

Address

:

Jl. Tololiu Supit No. 25 Manado SULAWESI UTARA

Phone No.

:

(0431) 851756

Fax

:

(0431) 851423

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

OLVIE ATTENG

II.

II. A.

T. HASUDUNGAN SIREGAR

III.

III. A.

DABY Y. N. NERWAN

IV.

SEAL

67



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN KOTA BITUNG (MUNICIPALITY OFFICE IN BITUNG)

Address

:

Jl. Wolter Mongonsidi 85 Bitung 95541, SULAWESI UTARA

Phone No.

:

(0438) 30006

Fax

:

(0438) 30006

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

FERRY R. BORORING

II.

II. A.

MEIDY P. MOHEDE

III.

III. A.

LUSYE KEMUR

IV.

IV.A.

OCTAVIANUS T.B. SANDA

IV.

SEAL

68



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN PROVINSI SULAWESI TENGGARA (PROVINCIAL OFFICE IN KENDARI)

Address

:

Jl. Drs. H. Abdullah Silondae No. 116 Kendari 93111, SULAWESI TENGGARA

Phone No.

:

(0401) 3128339

Fax

:

(0401) 3121783

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

SITTI SALEHA

II.

II. A.

MUHAMMAD ALI

III.

III. A.

HASNAWATI

IV.

SEAL

69



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN PROVINSI MALUKU (PROVINCIAL OFFICE IN AMBON)

Address

:

Jl. A.M Sangaji No.66 Ambon, MALUKU

Phone No.

:

(0911) 353219

Fax

:

(0911) 353219

E-mail

:

-

Name of Official :

Signature :

I

I. A.

F. J. PAPILAYA

II.

II. A.

E. PATTISELANNO

III.

III. A.

NY. W. TAHAMATA

IV.

SEAL

70



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN PROVINSI MALUKU UTARA (PROVINCIAL OFFICE IN TERNATE)

Address

:

Jl. Lintas Halmahera Gosale Puncak, Sofifi

Phone No.

:

(0921) 3128568, 3121685, 081388568861

Fax

:

(0921) 3128568, 3121685

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

MARTINUS DJAWA

II.

II. A.

M. SOFYAN AKBAR MS

III.

III. A.

FAHRIA ALI

IV.

SEAL

71



:

DINAS PERINDUSTRIAN PERDAGANGAN KOPERASI DAN UMKM PROVINSI PAPUA (PROVINCIAL OFFICE IN JAYAPURA)

Address

:

Jl. Matahari No. 25 Jayapura 99111 Kotak Pos 374, PAPUA

Phone No.

:

[0967] 551210

Fax

:

(0967) 534516

E-mail

:

-

Name of Official :

Signature :

I

I. A.

KALEB WOREMBAI

II.

II. A.

HERMAN BLESKADIT

III.

III. A.

MARIA CALOH

IV.

IV. A.

ROSALINA DE FRETES

IV.

SEAL

72



:

DINAS PERDAGANGAN KOPERASI DAN UMKM KABUPATEN MERAUKE (DISTRICT OFFICE IN MERAUKE)

Address

:

Jl. R.E. Martadinata No. 25 Po. 164-165 Merauke, PAPUA

Phone No.

:

(0971) 321722

Fax

:

(0971) 323768

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

BENI

II.

II. A.

BUDIYANTO

III.

III. A.

NURSYAM

IV.

SEAL

73



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN KABUPATEN BIAK NUMFOR (DISTRICT OFFICE IN BIAK)

Address

:

Jl. Goa Jepang Kotak Pos 15 Biak 98117, PAPUA

Phone No.

:

(0981) 21936

Fax

:

(0981) 23750

E-mail

:

-

Name of Official :

Signature :

I

I. A.

MULYONO PASANDE

II.

II. A.

NIKOLAS YONAS SROYER

III.

III. A.

NICO OJABA

IV.

SEAL

74



:

DINAS PERINDUSTRIAN, PERDAGANGAN, PENANAMAN MODAL, PERTAMBANGAN, PENGELOLAAN PASAR KABUPATEN KEPULAUAN YAPEN (DISTRICT OFFICE IN SERUI)

Address

:

Jl. Irian Serui, PAPUA, 98211

Phone No.

:

(0983) 31339, 31158

Fax

:

(0983) 31657

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

EDI NOCA MUDUMI

II.

II. A.

BAHRUDIN

III.

III. A.

UUL RESIA HARAHAP

IV.

SEAL

75



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN KABUPATEN SORONG (DISTRICT OFFICE IN SORONG)

Address

:

Jl. Klamono Km.24 Sorong , PAPUA

Phone No.

:

(0951) 321231

Fax

:

(0951) 333645

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

R. MARPAUNG

II.

II. A.

DJAMI’AT

III.

III. A.

KUSWATI

IV.

SEAL

76



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN KABUPATEN MANOKWARI (DISTRICT OFFICE IN MANOKWARI)

Address

:

Jl. Percetakan Negara Manokwari No. 18 Manokwari, PAPUA

Phone No.

:

(0986) 211011

Fax

:

(0986) 211786

E-mail

:

-

Name of Official :

Signature :

I

I. A.

STEPANUS SELANG

II.

II. A.

NICOLAUS WOOF

III.

III. A.

SUPOMO

IV.

SEAL

77



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN KABUPATEN FAK-FAK (DISTRICT OFFICE IN FAK-FAK)

Address

:

Jl. Jend. Sudirman Wagom Fak-Fak 98601, PAPUA

Phone No.

:

[0956] 22614

Fax

:

[ 0956] 22303

E-mail

:

-

Name of Official :

Signature :

I

I. A.

JULIUS MARIPADANG

II.

II. A.

EDI PAMBUDIO

III.

III. A.

WENSISLAUS RAHARUSUN

IV.

SEAL

78



:

DINAS KOPERASI,PERINDUSTRIAN DAN PERDAGANGAN KABUPATEN SERANG (DISTRICT OFFICE IN SERANG)

Address

:

Jl. Veteran No. 4 Serang 42117

Phone No.

:

(0254) 216737

Fax

:

(0254) 216744

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

TUBAGUS ENTUS MAHMUD SAHIRI

II.

II. A.

SUGANDA

III.

III. A.

CICIN RODIYAH

IV.

SEAL

79



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN KABUPATEN TANGERANG (DISTRICT OFFICE IN TIGARAKSA)

Address

:

Jl. Komplek Perkantoran Tigaraksa Gedung UsahaUsaha Daerah Jl. KH. Somawinata No. 4 Tigaraksa Tangerang 15111, Banten

Phone No.

:

(021) 5990498

Fax

:

(021) 5990516

E-mail

:

-

Name of Official :

Signature :

I.

I. A.

TUTI SUJANA

II.

II. A.

DWI EKA APRILLIA PUTRI III.

III. A.

JUNAEDI IV. AKHMAD TITO GIARTHO

IV.

SEAL

80

MINISTRY OF TRADE REPUBLIC OF INDONESIA Specimen of Signature, and Specimen of Official Seal Authorized To Certify The Certificate Of Origin From Indonesia DINAS PERINDUSTRIAN, PERDAGANGAN DAN KOPERASI KOTA TANGERANG (MUNICIPALITY OFFICE IN TANGERANG) Gedung Pusat Pemerintahan Lantai III Jl. Satria Sudirman No. 1 Tangerang Banten


:

Address

:

Phone No.

:

(021) 55764945 – 55764955 Ext. 600 s.d 606

Fax

:

(021) 55764945

E-mail

:

-

Name of Official :

Signature :

I.

I. A.

MUHAMAD NOOR

II.

II. A.

SUDADI III.

III. A.

OKE SULENDRO SETYO RACHMAN

IV. EKO CAHYONO

IV.

SEAL

81



:

DINAS PERINDUSTRIAN PERDAGANGAN DAN KOPERASI KOTA CILEGON (MUNICIPALITY OFFICE IN CILEGON)

Address

:

Jl.Jenderal Sudirman No. 02 Cilegon, BANTEN

Phone No.

:

(0254) 380577 ext 321

Fax

:

(0254) 389024

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

AKHMAD DITA PRAWIRA

II.

II. A.

MUHAMAD SATIRI

III.

III. A.

NURMA KAHARANSIYAH

IV.

SEAL

82



:

DINAS PERINDUSTRIAN DAN PERDAGANGAN PROVINSI KEPULAUAN BANGKA BELITUNG (PROVINCIAL OFFICE IN PANGKAL PINANG)

Address

:

Jl. Pulau Bangka Komplek Perkantoran Pem. Prov Kepulauan Bangka Belitung , PANGKALPINANG

Phone No.

:

(0717) 439093

Fax

:

(0717) 439093

E-mail

:

[email protected]

Name of Official :

Signature :

I

I. A.

SUHARTO

II.

II. A.

R. MUHAMMAD AYUB

III.

III. A.

-

IV.

SEAL

83



:

DINAS PERINDUSTRIAN PERDAGANGAN, KOPERASI DAN PENANAMAN MODALKABUPATEN BELITUNG (DISTRICT OFFICE IN TANJUNG PANDAN)

Address

:

Jl. R.E. Martadinata No. 8 Tanjung Pandan 33411, KEPULAUAN BANGKA BELITUNG

Phone No.

:

(0719) 21053

Fax

:

(0719) 22272

E-mail

:

-

Name of Official :

Signature :

I

I. A.

MZ. HENDRA CAYA

II.

II. A.

JONTIAR HUTAPEA

III.

III. A.

ISMAIL

IV.

SEAL

84



:

DINAS KOPERASI, PERINDUSTRIAN DAN PERDAGANGAN PROVINSI GORONTALO (PROVINCIAL OFFICE IN GORONTALO)

Address

:

Jl. Tengah Desa Toto Selatan, Kecamatan Kabila Kabupaten Bone Bolango, Gorontalo

Phone No.

:

[0435] 831606

Fax

:

[0435] 831607

E-mail

:

-

Name of Official :

Signature :

I

I. A.

ARJON PARIS

II.

II. A.

SOFYAN J.PULO’O

III.

III. A.

RUSOVANNY HALALUTU

IV.

SEAL

85


DINAS PERINDUSTRIAN DAN PERDAGANGAN


:

Address

: Jl. W.J.Lalamentik, Oepoi - KUPANG

Phone No.

: (0380) 823229

Fax

: (0380) 833144

E-mail

: [email protected]

PROVINSI NUSA TENGGARA TIMUR (PROVINCIAL OFFICE IN KUPANG)

Name of Official :

Signature :

I

I. A.

ANTONIUS M.R.SANTOSA

II.

II. A.

ALOYSIUS MIN

III.

III. A.

STANISLAUS

IV.

SEAL

86

MINISTRY OF TRADE NURDIN ZULFIKAR SUSILAWATI REPUBLIC OF INDONESIA. Name of Official : Signature : II. II. A. III. III. A

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