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

NO
NO

YES (Explain in Block 11)

YES (Explain in Block 11)

5.  IS THE APPLICANT AN OFFICER OR EMPLOYEE OF THE UNITED STATES?

3. CUSTOMS PORT

DEPARTMENT OF THE TREASURY
United States Customs Service Application for Customs Broker License Exam.
19 U S C 16 41;
19 C F R 111.13. 4.  DOES THE APPLICANT SEEK ACCOMODATIONS UNDER THE AMERICAN DISABILITIES ACT? 5.  IS THE APPLICANT AN OFFICER OR EMPLOYEE OF THE UNITED STATES?

Customs Form 3124E (06/00)

Customs Form 31 24 E (06/00) Form Assistant Page 1 of 3

Form Assistant
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