Form 4455 - Certificate Of Registration - Certificate Of Registration - Sample

DEPARTMENT OF THE TREASURY

Form Approved. OMB No. 1515-0014

UNITED STATES CUSTOMS SERVICE

NO.

CERTIFICATE OF REGISTRATION

(NOTE: Number of copies to be submitted varies with type of transaction.

19 CFR 10.8, 10.9, 10.68,

Inquire at Port Director's office as to number of copies required.)

148.1, 148.8, 148.32, 148.37

B/L or INSURED NO.

DATE

VIA (Carrier)

NAME, ADDRESS, AND ZIP CODE TO WHICH CERTIFIED FORM IS TO BE

ARTICLES EXPORTED FOR:

MAILED (If Applicable)

ALTERATION*

PROCESSING*

REPAIR*

OTHER, (specify)

USE ABROAD

REPLACEMENT

* NOTE: The cost or value of alterations, repairs, or processing

abroad is subject to customs duty.

LIST ARTICLES EXPORTED

Number

Kind of

Description

Packages

Packages

S A M P L E

SIGNATURE OF OWNER OR AGENT (Print or Type and Sign)

DATE

The Above-Described Articles Were:

EXAMINED

LADEN under my supervision

DATE

PORT

DATE

PORT

SIGNATURE OF CUSTOMS OFFICER

SIGNATURE OF CUSTOMS OFFICER

CERTIFICATE ON RETURN

Duty-free entry is claimed for the described articles as having been exported without benefit of drawback and are returned unchanged except as noted: (use reverse if needed)

SIGNATURE OF IMPORTER (Print or Type and Sign)

DATE

NOTE: Certifying officers shall draw lines through all unused spaces with ink or indelible pencil.

PAPERWORK REDUCTION ACT NOTICE: The Paperwork Reduction Act of 1980 says we must tell you why we are collecting this informaiton, how we will use it, and whether you have to give it to u

ask for the information to carry out the Customs Service laws of the United States. We need the information to ensure that importers/exporters are complying with these laws in claiming duty free entr

exported articles which are then returned into the United States. Your response is mandatory and to your benefit.

Customs Form 4455 (090298)