Customs Form 4455 - Certificate Of Registration - United States Customs Service

Form Approved. OMB No. 1515-0042

DEPARTMENT OF THE TREASURY

NO.

United States Customs Service

CERTIFICATE OF REGISTRATION

19 CFR 10.8, 10.9, 10.68,

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

148.1, 148.8, 148.32, 148.37

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

DATE

VIA (Carrier)

B/L or INSURED NO.

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

ARTICLES EXPORTED FOR:

MAILED (If Applicable)

ALTERATION*

PROCESSING*

(specify)

REPAIR*

OTHER,

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

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: This request is in accordance with the Paperwork Reduction Act of 1995. The information to be provided is submitted by importers/exporters.

Completion of this form is mandatory and to your benefit. The estimated average burden associated with this collection of information is 3 minutes per respondent depending on

individual circumstances. Comments concerning the accuracy of this burden estimates and suggestions for reducing this burden should be directed to U.S. Customs Service,

Information Service Branch, Washington, DC 20229, and to the Office of Management and Budget, Paperwork Reduction Project (1515-0042), Washington, DC 20503.

Customs Form 4455 (06/00)