1. ZONE NO. AND LOCATION (Address)

23. DATE

21. FOR THE FTZ OPERATOR: (Signature)

22. TITLE

20. TO THE PORT DIRECTOR OF CUSTOMS:

FTZ OPERATOR'S RETURN

19. DATE

17. PORT DIRECTOR OF CUSTOMS: By (Signature)

18. TITLE

The application made above is hereby approved and permission is granted to manipulate, manufacture, exhibit, destroy, or temporarily removed, as requested, on condition that the applicable regulations are complied with and the records required to be maintained will be available for inspection.

PERMIT

16. TITLE

15. BY (Signature)

APPROVED BY FOREIGN- TRADE ZONE OPERATOR

14. TITLE

13. BY (Signature)

12. APPLICANT FIRM NAME

If any merchandise is to be manipulated in any way or manufactured, I agree to maintain the records provided for in sections 146.21(a), 146.23, and 146.52(d) of the Customs Regulations and to make them available to customs officers for inspection.

4.  TYPE OF ACTIVITY FOR WHICH PERMIT REQUESTED

19 CFR 146.52, 146.66

3. APPLICATION DATE

2. ZONE ADMISSION NO.

Approved through OMB No. 1515-0086.

DEPARTMENT OF THE TREASURY 
United States Customs Service

APPLICATION  FOR FOREIGN-TRADE  ZONE

ACTIVITY  PERMIT

Any data typed after screen scrolls will not print.

Manipulate
Manufacture
Exhibit
Destroy
Temporary Removal

I certify that the goods described herein have been disposed of as directed except as noted below.

Customs Form 216 (01/01)

(mm/dd/yyyy)

(This is a mandatory field)

(mm/dd/yyyy)

(mm/dd/yyyy)

Department of the Treasury
United States Customs Service Application for Foreign-Trade Zone Activity Permit. Any data typed after screen scrolls will not print. Approved through O M B Number 1 5 1 5 - 0 0 8 6. 19 C F R 146.52,
146.66 4. Type of Activity for which permit requested. 5.  FULL DESCRIPTION OF THE ACTIVITY (Include designation of the exact place in zone where the operation is to be performed and, in the case of "A" proposed manipulation or manufacture, "A" statement as to whether merchandise with one zone status is to be packed, commingled, or combined with merchandise having diffrent zone status.  If additional space required, attach separate sheet.  If first application for manufacturing of this kind, state whether Foreign-Trade Zones board has occurred in proposed operation.) If any merchandise is to be manipulated in any way or manufactured, I agree to maintain the records provided for in sections 146.21("A"), 146.23, and 146.52(d) of the Customs Regulations and to make them available to customs officers for inspection. APPROVED BY FOREIGN-TRADE ZONE OPERATOR. PERMIT The application made above is approved and permission is granted to manipulate, manufacture, exhibit, destroy, or temporarily removed, as requested, on condition that the applicable regulations are complied with and the records require to be maintained will be available for inspection. F T Z Operator's Return 20. To the Port Director of Customs: Customs Form 216 (01 / 01)

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ZONE LOT NO. OR UNIQUE IDENTIFIER

QUANTITY

WEIGHTS, MEASURES

ZONE STATUS

DESCRIPTION OF MERCHANDISE

8.

7.

6.

9.

10.

11.

MARKS AND NUMBERS

5.  FULL DESCRIPTION OF THE ACTIVITY (Include designation of the exact place in zone where the operation is to be performed and, in the case of a proposed manipulation or

manufacture, a statement as to whether merchandise with one zone status is to be packed, commingled, or combined with merchandise having diffrent zone status.  If additional

space required, attach separate sheet.  If first application for manufacturing of this kind, state whether Foreign-Trade Zones board has occurred in proposed operation.)