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
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?
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
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?
Any data typed after screen scrolls will not print.
Customs Form 3124 (06/00)
Form Assistant
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