(country code, if applicable)

Receive Date

Date
Issued

Port
Code

Issued
By

DEPARTMENT OF THE TREASURY
UNITED STATES CUSTOMS SERVICE
ANNUAL USER FEE DECAL REQUEST - COMMERCIAL VEHICLE

Mail Date

Cash
Receipt No.

Si usted no habla o escribe Ingles y necessita ayuda en espanol para llenar este documento, llame a la oficina de Aduanas de Estados Unidos mas cercana a usted. Este servicio es gratuito.

Customs Use Only

Page

of

City, State/Province

1A  Ship To:

Address

Country    Zip

Address

Requester's Name

Calendar Year for which
Decal(s) requested:

Customs Form 339C (07/01)

1. A. See oosted no abla o escree be Ing les ee necessee ta ayuda en espanol para lle nar es te documento, lla me a la oficina de Aduanas de Esta dos Unee dos mas cercana a oosted. Es te servicio es gratuito.

APPLICANT PHONE NUMBER

APPLICANT FAX NUMBER

Customs Form 339C (07/01) DEPARTMENT OF THE TREASURY. UNITED STATES CUSTOMS SERVICE.  ANNUAL USER FEE DECAL REQUEST - COMMERCIAL VEHICLE 1. B.

1B

(country code, if applicable)

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