(b)
(c)
(d)
(e)
OMB No. 1651-0034 Exp. 03-31-2011
See back of form for Paperwork Reduction Act Notice.
1. APPLICANT'S NAME AND ADDRESS (Principal Office)
(Indicate fictitious name, if applicable)
2. TYPE OF LICENSE APPLIED FOR
3. CBP PORT
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?
SECTION I - INDIVIDUALS ONLY
10. HOME PHONE NO.
11. BUSINESS PHONE NO.
7. DATE OF BIRTH
9. SOCIAL SECURITY NO.
8. BIRTHPLACE (City & State)
12. U.S. CITIZENSHIP
14. RESIDENCE ADDRESS (If different from Block 1; if same, write "SAME")
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.)
17. LIST THE NAMES, ADDRESSES, AND PHONE NUMBERS OF SIX REFERENCES
18. REMARKS (In responding to questions above, include Block no. If more space is needed continue on blank sheet of paper.)
APPLICATION
FOR
CUSTOMS BROKER LICENSE
19 U.S.C. 1641; 19 CFR 111.12
CBP Form 3124 (06/09)
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
Individual
Corporation
Partnership
Association
NO
NO
NO
NATURAL-BORN
NO
NO
(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.)
YES (Explain in Block 18)
YES (Explain in Block 18)
YES (Explain in Block 18)
YES (Exp