OMB No. 1515-0076; see back of form for Paperwork Reduction Act Notice.

1. APPLICANT'S NAME AND ADDRESS (Principal Office) (Indicate fictitious name, if applicable)

2. TYPE OF LICENSE APPLIED FOR

3. CUSTOMS PORT

5.  HAS THE APPLICANT (OR ANY OFFICER, MEMBER, OR PRINCIPAL 

     THEREOF AS IDENTIFIED IN BLOCK 22) EVER HAD A LICENSE 

     SUSPENDED, REFUSED, REVOKED, OR CANCELLED?

APPLICATION

FOR 

CUSTOMS BROKER LICENSE

DEPARTMENT OF THE TREASURY 
United States Customs Service

19 U.S.C. 1641; 19 CFR 111.12

INSTRUCTIONS:  Applicants must be United States citizens.  Pursuant to the requirements of 19CFR 111.12 (b) the information contained in Blocks 1,2,3,22 and 23 may be released to the public and posted by appropriate electronic means.  Submit application in duplicate to the Port Director of the Port name in Block 3.  All additional continuation sheets, if required, and attachments should be in duplicate

Individual
Corporation
Partnership
Association
NO
NO
NO

YES (Explain in Block 18)

YES (Explain in Block 18)

YES (Explain in Block 18)

4. HAVE YOU EVER APPLIED FOR A CUSTOMS BROKER'S LICENSE?

6. IS THE APPLICANT (OR ANY OFFICER, MEMBER OR PRINCIPAL THEREOF AS   

    IDENTIFIED IN BLOCK 22) AN OFFICER OR EMPLOYEE OF THE UNITED STATES?

DEPARTMENT OF THE TREASURY
United States Customs Service Application for Customs Broker License
19 U S C 16 41;
19 C F R 111.12 O M B Number 15 15-0 0 76; See back of form for Paperwork Reduction Act Notice.

Any data typed after screen scrolls will not print.

Any Data Typed after screen scrolls will not print. INSTRUCTIONS:  Applicants must be United States citizens.  Pursuant to the requirements of 19 C F R 111.12 (b) the information contained in Blocks 1,2,3,22 and 23 may be released to the Public and posted by appropriate electronic means. Submit application in duplicate to the Port Director to the Port name in Block 3.  All additional continuation sheets, if required, and attachments should be in duplicate. 2. TYPE OF LICENSE APPLIED FOR 4. Have you ever applied for a Customs Broker's License? 5. Has the Applicant (or any Officer, Member, or Principal thereof as identified in Block 22) Ever had a License Suspended, Refused, Revoked, or Cancelled? 6. Is the Applicant (or any Officer, Member or Principal thereof as Identified in Block 22) an Officer or Employee of The United States?

Customs Form 3124 (06/00)

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