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<div id="iddivformheaderbc40">
<?php
/* 	$rows = 10; // define number of rows
	$cols = 4;// define number of columns
	 
	echo "<table border='1'>";
	 
	for($tr=1;$tr<=$rows;$tr++){
		  
		echo "<tr>";
			for($td=1;$td<=$cols;$td++){
				   echo "<td>row: ".$tr." column: ".$td."</td>";
			}
		echo "</tr>";
	}
	 
	echo "</table>"; */
?>


<table width="940" border="0" cellspacing="0" cellpadding="2">
  <tr>
    <td width="134" rowspan="2" style="border-top:1px #000000 solid;border-left:1px #000000 solid;font-weight:bold;border-right:1px #000000 solid;font-family:'Times New Roman';font-size:12px;"><div align="center">BC 4.0</div></td>
    <td width="817" style="border-top:1px #000000 solid;border-right:1px #000000 solid;font-weight:bold; font-size:12px;font-family:'Times New Roman';"><div align="center">PEMBERITAHUAN PEMASUKAN BARANG ASAL TEMPAT LAIN </div></td>
  </tr>
  <tr>
    <td class="style3" style="border-right:1px #000000 solid;font-weight:bold; font-size:12px;font-family:'Times New Roman';"><div align="center">DALAM DAERAH PABEAN KE TEMPAT PENIMBUNAN BERIKAT </div></td>
  </tr>
</table>
<table width="940" border="0" cellspacing="0" cellpadding="2">
  <tr>
    <td colspan="8" style="border-top:1px #000000 solid;border-left:1px #000000 solid;border-right:1px #000000 solid;font-size:11px;text-align:left;font-weight:bold; font-size:11px;border-bottom:1px #000000 solid;font-family:'Times New Roman', Times, serif;">HEADER&nbsp;</td>
  </tr>
  <tr>
  <td colspan="2"  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">NOMOR PENGAJUAN </td>
    <td width="10" style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td width="257" style="font-family:'Times New Roman', Times, serif; font-size:11px;"><?php echo $BC23No; ?></td>
    <td width="10" style="font-family:'Times New Roman', Times, serif; font-size:11px;"></td>
    <td width="302" style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
	<td width="21" style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
	<td width="143" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-right:1px #000000 solid;">Hal</td>
  </tr>
  <tr>
    <td width="138" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;A.&nbsp;&nbsp;&nbsp;KANTOR PABEAN</td>
    <td width="27" style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">KPBC MADYA PABEAN TANGERANG</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="border-top:1px solid #000000;border-left:1px #000000 solid;"><span style="font-family:'Times New Roman', Times, serif; font-size:11px;font-weight:bold">F.&nbsp;&nbsp;KOLOM KHUSUS BEA DAN CUKAI</span></td>
	<td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-top:1px #000000 solid;" >:</td>
	<td style=";border-right:1px #000000 solid;border-top:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif;font-size:11px;border-left:1px #000000 solid;">&nbsp;B.&nbsp;&nbsp;&nbsp;JENIS TPB</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="border-left:1px #000000 solid;font-size:11px;;"><span style="font-family:'Times New Roman', Times, serif;">Nomor Pendaftaran </span></td>
	<td style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
	<td style="font-family:'Times New Roman', Times, serif;font-size:11px;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif;font-size:11px;border-left:1px #000000 solid;">&nbsp;C.&nbsp;&nbsp;&nbsp;TUJUAN PENGIRIMAN</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">:&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif;font-size:11px;">DI JUAL </td>
    <td>&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">Tanggal</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
</table>
<table width="940" border="0" cellspacing="0" cellpadding="2">
  <tr>
    <td colspan="7" style="border-top:1px #000000 solid;border-bottom:1px #000000 solid;border-left:1px #000000 solid;border-right:1px #000000 solid;font-size:11px;font-weight:bold;font-family:'Times New Roman', Times, serif;">D. DATA PEMBERITAHUAN</td>
  </tr>
  <tr>
    <td colspan="4" style="font-family:'Times New Roman', Times, serif;border-left:1px #000000 solid;border-bottom:1px #000000 solid;font-size:11px;font-weight:bold;">PENGUSAHA TPB</td>
    <td colspan="3"  style="font-family:'Times New Roman', Times, serif;border-left:1px #000000 solid;border-right:1px #000000 solid;border-bottom:1px #000000 solid;font-size:11px;font-weight:bold">PENERIMA BARANG</td>
  </tr>
  <tr>
    <td width="131" style="border-left:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">1. NPWP</td>
    <td width="23" style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td width="234" style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td width="57">&nbsp;</td>
    <td width="201" style="border-left:1px #000000 solid; font-family:'Times New Roman', Times, serif; font-size:11px;">5. NPWP</td>
    <td width="24" style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td width="242" style="border-right:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
  </tr>
  <tr>
    <td  style=";border-left:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">2. Nama</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style=";border-left:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">6. Nama</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td style="border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td  style=";border-left:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">3. Alamat</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style=";border-left:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">7. Alamat</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td style="border-right:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
  </tr>
  <tr>
    <td style=";border-left:1px #000000 solid;">&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td style=";border-left:1px #000000 solid;">&nbsp;</td>
    <td>&nbsp;</td>
    <td style="border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">4. No Izin TPB</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td colspan="4"   style="border-top:1px #000000 solid;border-bottom:1px #000000 solid;border-left:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;font-weight:bold">DOKUMEN PELENGKAP PABEAN</td>
    <td colspan="3"  style="border-top:1px #000000 solid;border-bottom:1px #000000 solid;border-left:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
</table>
<table width="940" border="0" cellspacing="0" cellpadding="2">
  <tr>
    <td width="100"  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">8. Packing list</td>
    <td width="32" style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;:</td>
    <td colspan="3" style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td width="52" style="font-family:'Times New Roman', Times, serif; font-size:11px;" >Tgl</td>
    <td width="20" style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td width="121" style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td width="13" style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td colspan="3" style="font-family:'Times New Roman', Times, serif; font-size:11px;">10. Surat Keputusan/Persetujuan</td>
    <td width="71" style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td width="116" style="border-right:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
  </tr>
  <tr>
    <td  style="border-left:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">9. Kontrak</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;:</td>
    <td colspan="3" style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">Tgl</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td width="98" style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td width="26" style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td width="77" style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">Tgl</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="border-left:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td colspan="3" style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td colspan="3" style="font-family:'Times New Roman', Times, serif; font-size:11px;" >11. Jenis/Nomor/tanggal dokumen lainnya</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-right:1px #000000 solid;">:</td>
  </tr>
  <tr>
    <td style="border-left:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td colspan="3" style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">Tgl</td>
    <td style="border-right:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
  </tr>
  <tr>
    <td style="border-left:1px #000000 solid;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td colspan="3" style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="border-right:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
  </tr>
  <tr>
    <td colspan="14"  style="border-top:1px #000000 solid;border-bottom:1px #000000 solid;border-left:1px #000000 solid;border-right:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;font-weight:bold">DATA PENGANGKUTAN</td>
  </tr>
  <tr>
    <td colspan="3"  style="border-left:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">12. Jenis sarana pengangkutan darat</td>
    <td width="24"  style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td width="94"  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">13. Nomor Polisi</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="border-right:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
  </tr>
  <tr>
    <td style="border-left:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td width="40" tyle="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="border-right:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
  </tr>
  <tr>
    <td colspan="14"  style="border-top:1px #000000 solid;border-bottom:1px #000000 solid;border-left:1px #000000 solid;border-right:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;font-weight:bold">DATA PERDAGANGAN</td>
  </tr>
  <tr>
    <td colspan="2"  style="border-left:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">14. Harga Penyerahan</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="border-right:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
  </tr>
  <tr>
    <td style="border-left:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="border-right:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
  </tr>
  <tr>
    <td colspan="14"  style="border-top:1px #000000 solid;border-bottom:1px #000000 solid;border-left:1px #000000 solid;border-right:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;font-weight:bold">DATA PENGEMAS</td>
  </tr>
  <tr>
    <td colspan="2"  style="border-left:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">15. Jenis Kemasan</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;" >17. Jenis Kemasan</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="border-right:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
  </tr>
  <tr>
    <td colspan="2"  style="border-left:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">16. Merek Kemasan</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td style="border-right:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
  </tr>
  <tr>
    <td colspan="14"  style="border-top:1px #000000 solid;border-bottom:1px #000000 solid;border-left:1px #000000 solid;border-right:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;font-weight:bold">DATA BARANG</td>
  </tr>
  <tr>
    <td  style="border-left:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">18. Volume (m3)</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;" colspan="6">:</td>
    <td colspan="2"  style="font-family:'Times New Roman', Times, serif; font-size:11px;">19. Berat Kotor (kg) :</td>
    <td colspan="3" style="font-family:'Times New Roman', Times, serif; font-size:11px;">&nbsp;</td>
    <td colspan="2"  style="border-right:1px #000000 solid;font-family:'Times New Roman', Times, serif; font-size:11px;">20. Berat Bersih :</td>
  </tr>
</table>
 <table width="940" border="0" cellspacing="0" cellpadding="2">
  
      <tr><td width="36"  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-top:1px #000000 solid;">21.</td>
        <td colspan="2"  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-top:1px #000000 solid;border-left:1px #000000 solid;">22.</td>
    <td width="133"  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-top:1px #000000 solid;">23.</td>
    <td width="322"  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;border-top:1px #000000 solid;">24.</td>
  </tr>
  <tr>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">No.</td>
    <td colspan="2"  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;"> Uraian jumlah dan jenis barang secara lengkap, kode barang, merk, tipe, ukuran, </td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">- Jumlah dan Jenis Satuan</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">- Nilai CIF </td>
  </tr>
  <tr>
    <td rowspan="2" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-bottom:1px #000000 solid;">&nbsp;</td>
    <td colspan="2"  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;"> dan spesifikasi lain</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">- Berat Bersih (kg)</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">-Harga</td>
  </tr>
  <tr>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-bottom:1px #000000 solid;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-bottom:1px #000000 solid;">- Volume</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;border-bottom:1px #000000 solid;">Penyerahan</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-bottom:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-bottom:1px #000000 solid;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-bottom:1px #000000 solid;">&nbsp;</td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;border-bottom:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-weight:bold;font-size:11px;border-left:1px #000000 solid;border-bottom:1px #000000 solid;">G.</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-weight:bold; font-size:11px;border-left:1px #000000 solid;border-bottom:1px #000000 solid;">UNTUK PEJABAT BEA DAN CUKAI</td>
    <td colspan="2"  style="font-family:'Times New Roman', Times, serif;font-weight:bold; font-size:11px;border-left:1px #000000 solid;border-bottom:1px #000000 solid;border-right:1px #000000 solid;">E. TANDA TANGAN PENGUSAHA TPB</td>
    </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-weight:bold;font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-weight:bold; font-size:11px;"></td>
    <td colspan="2"  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">Dengan ini saya menyatakan bertanggung jawab atas kebenaran hal hal</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-weight:bold;font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-weight:bold; font-size:11px;"></td>
    <td colspan="2"  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">yang diberitahukan dalam pemberitahuan pabean ini </td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-weight:bold;font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-weight:bold; font-size:11px;"></td>
    <td colspan="2"  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-weight:bold;font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-weight:bold; font-size:11px;"></td>
    <td colspan="2"  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-weight:bold;font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-weight:bold; font-size:11px;"></td>
    <td colspan="2"  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-weight:bold;font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td width="50" style="font-family:'Times New Roman', Times, serif;font-size:11px;">Nama</td>
    <td width="379" style="font-family:'Times New Roman', Times, serif;font-size:11px;">:</td>
    <td colspan="2"  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;"><div align="center">Balaraja, </div></td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-weight:bold;font-size:11px;border-left:1px #000000 solid;">&nbsp;</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">NIP</td>
    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;">:</td>
    <td colspan="2"  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;"><div align="center">JUAN P. SIAGIAN </div></td>
  </tr>
  <tr>
    <td style="font-family:'Times New Roman', Times, serif; font-weight:bold;font-size:11px;border-left:1px #000000 solid;border-bottom:1px #000000 solid;">&nbsp;</td>
    <td colspan="2" style="font-family:'Times New Roman', Times, serif; font-weight:bold; font-size:11px;border-bottom:1px #000000 solid;">&nbsp;</td>
    <td colspan="2"  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-bottom:1px #000000 solid;border-right:1px #000000 solid;">&nbsp;</td>
  </tr>
  
  <tr>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;"></td>
    <td colspan="2"  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;"></td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;"></td>
    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;"></td>
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	<td style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;"></td>
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    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;"></td>
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    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;"></td>
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    <td  style="font-family:'Times New Roman', Times, serif; font-size:11px;border-left:1px #000000 solid;border-right:1px #000000 solid;"></td>
  </tr>
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    <td style="font-family:'Times New Roman', Times, serif; font-size:11px;"></td>
  </tr>
</table>


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