552a e 3 that the authority to collect information on CBP Form 3124 is 19 U.S.C. 1641 5 U.S.C. 301 Reorganization plan no. If more space is needed continue on blank sheet of paper. CBP Form 3124 07/14 SECTION II -- FOR ASSOCIATION CORPORATION OR PARTNERSHIP ONLY 19. OMB No* 1651-0034 Exp* 07-31-2017 See back of form for Paperwork Reduction Act Notice. DEPARTMENT OF HOMELAND SECURITY U*S* Customs and Border Protection 1. APPLICANT S NAME AND ADDRESS Principal Office Indicate fictitious name if applicable APPLICATION FOR CUSTOMS BROKER LICENSE 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 2. TYPE OF LICENSE APPLIED FOR Individual Corporation Partnership Association 3. CBP PORT 4. HAVE YOU EVER APPLIED FOR A CUSTOMS BROKER S LICENSE NO YES Explain in Block 18 5. HAS THE APPLICANT OR ANY OFFICER MEMBER OR PRINCIPAL THERE OF AS IDENTIFIED IN BLOCK 22 EVER HAD A LICENSE SUSPENDED REFUSED REVOKED OR CANCELLED 6. IS THE APPLICANT OR ANY OFFICER MEMBER OR PRINCIPAL THEREOF AS IDENTIFIED IN BLOCK 22 AN OFFICER OR EMPLOYEE OF THE UNITED STATES 7. DATE OF BIRTH 12. U*S* CITIZENSHIP NATURAL-BORN 8. BIRTHPLACE City State SECTION I - INDIVIDUALS ONLY 9. SOCIAL SECURITY NO. 10. HOME PHONE NO. 11. BUSINESS PHONE NO. NATURALIZED Give Date and Place 13. HAVE YOU EVER BEEN ARRESTED CHARGED CONVICTED OF OR FORFEITED COLLATERAL FOR ANY FELONY MISDEMEANOR OR OTHER VIOLATION 14. RESIDENCE ADDRESS If different from Block 1 if same write SAME You may omit 1. traffic violations for which you paid a fine of 250 or less 2. any incident which happened before your 16th birthday. All other incidents must be included even though the case records were expunged or suppressed under a rehabilitation program or you were sentenced under a State statute which provides that you need not report the incident when applying for employment a license etc* 15. IN THE LAST 5 YEARS HAVE YOU OR A COMPANY OVER WHICH YOU EXCERCISED SOME CONTROL FILED FOR BANKRUPTCY BEEN DECLARED BANKRUPT BEEN SUBJECT TO A TAX LIEN OR HAD LEGAL JUDGEMENT RENDERED AGAINST YOU FOR A DEBT 16. DO YOU PROPOSE TO ENGAGE IN THE BUSINESS OF A CUSTOMS BROKER More than one may apply. Explain answers in Block 18. a ON YOUR OWN INDIVIDUAL ACCOUNT State name in which business is to be conducted if trade name state authority for use of the name and attach evidence of such authority. b AS A MEMBER OF A PARTNERSHIP State name of partnership and list names of all the partners. c AS AN OFFICER OF AN ASSOCIATION State name of the association the title of the office you hold and the general nature of your duties. d e AS AN EMPLOYEE State name and address of your employer if different from Block 1 write SAME and the nature of your employment.
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