1. APPLICANT'S NAME AND ADDRESS
2. RESIDENCE ADDRESS (If different from Block 1; if same, write "SAME")
4. DOES THE APPLICANT SEEK ACCOMODATIONS UNDER THE AMERICAN
DISABILITIES ACT?
APPLICATION
FOR
CUSTOMS BROKER LICENSE EXAM
DEPARTMENT OF THE TREASURY
United States Customs Service
19 U.S.C. 1641; 19 CFR 111.13
YES (Explain in Block 11)
YES (Explain in Block 11)
5. IS THE APPLICANT AN OFFICER OR EMPLOYEE OF THE UNITED STATES?
Customs Form 3124E (06/00)
Form Assistant
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OMB. No. 1515-0076; see bottom of form for Paperwork Reduction Act Notice.
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