Form Ap-168 - Texas Application For Customs Broker License Page 4
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4Texas Application for
AP-168-4
(Rev.1-15/7)
Customs Broker License
• Please read instructions.
• Type or print.
• Do NOT write in shaded areas.
Page 3
32. Legal name of applicant (same as Item 2)
Texas Customs Broker license number
Complete the following information for every employee authorized to issue certifications. A power of attorney is required for each employee
authorized to issue certifications. Include any officers that will issue certificates. (Attach additional sheets as necessary.)
33. Name of employee (First name, middle initial, last name)
34. Social Security number
35. Home address (Street and number, P.O. Box or rural route)
City
County/Country
State/Province ZIP/Postal code
Month
Day
Year
Employee
36. Beginning date ................................
taxpayer no.
37. Email
38. Phone number
address
(Area code and number)
39. Name of employee (First name, middle initial, last name)
40. Social Security number
41. Home address (Street and number, P.O. Box or rural route)
City
County/Country
State/Province ZIP/Postal code
Month
Day
Year
Employee
42. Beginning date ................................
taxpayer no.
43. Email
44. Phone number
address
(Area code and number)
45. Name of employee (First name, middle initial, last name)
46. Social Security number
47. Home address (Street and number, P.O. Box or rural route)
City
County/Country
State/Province ZIP/Postal code
Month
Day
Year
Employee
48. Beginning date ................................
taxpayer no.
49. Email
50. Phone number
address
(Area code and number)
51. Name of employee (First name, middle initial, last name)
52. Social Security number
53. Home address (Street and number, P.O. Box or rural route)
City
County/Country
State/Province ZIP/Postal code
Month
Day
Year
Employee
54. Beginning date ................................
taxpayer no.
55. Email
56. Phone number
address
(Area code and number)
57. Name of employee (First name, middle initial, last name)
58. Social Security number
59. Home address (Street and number, P.O. Box or rural route)
City
County/Country
State/Province ZIP/Postal code
Month
Day
Year
Employee
60. Beginning date ................................
taxpayer no.
61. Email
62. Phone number
address
(Area code and number)
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