Signature of Customs Officer

Date/Time

No.

APPROVED

CUSTOMS USE ONLY

Form Approved OMB No. 1515-0013

APPLICATION-PERMIT-SPECIAL LICENSE UNLADING-LADING-OVERTIME SERVICES

United States Customs Service

8. Locations  (Dock/Terminal)*

2. Port

4. Name and Nationality of Owner/Operator

7. Date/Time of Arrival

3. Flag

1. Name of Vessel, Vehicle or Aircraft

19 CFR 4.10, 4.30, 4.37, 4.39, 4.91, 10.60, 24.16, 122.29, 122.38, 123.8, 146.32, 146.34

6. Arriving from
    (Port Name and Country)

United States Customs Service Application-Permit-Special License, Unlading-Lading-Overtime Services 19 C F R 4.10, 4.30, 4.37, 4.39, 4.91, 10.60, 24.16, 122.29, 122.38, 123.8, 146.32, 146.34 Form Approved O M B Number 15 15-00 1 3 Customs Use Only (This is a protected field)

Customs Form 3171 (01/02)

Customs Form 31 71 (01/02) Form Assistant Page 1 of 5

Form Assistant
Page 1 of 5

Go to Form Assistant Page (1-5):

Day Phone

Night Phone

5. Name/Phone No. of Agent

(country code, if applicable for both)