Approved OMB NO. 1651-0064
See back of form for Paperwork Reduction Act Notice.
1. TYPE OF ACTION (Mark all applicable)
Change of address*
Check here if you also want your
address updated in the Fines,
Penalties, and Forfeitures Office
Change of name*
*NOTE--If a continuous bond is on file, a rider must accompany this change document.
19 CFR 24.5
2. IMPORTER NUMBER (Fill in one format):--
2A. I.R.S. Number
2B. Social Security Number
Check here if requesting a
CBP-assigned number and
indicate reason(s). (Check all that apply.)
I have no
Social Security No.
I have not applied
for either number.
I am not a
I have no IRS No.
2D. CBP-Assigned Number
3. Importer Name
5. DIV/AKA/DBA Name
7. Importer Mailing Address (2 32-character lines maximum)
9. State Code
11. Country ISO Code (Non-U.S. Only)
12. Importer Physical Location Address (2 32-character lines maximum, see instructions)
14. State Code
16. Country ISO Code (Non-U.S. Only)
17a. Has importer ever been assigned a CBP Importer Number using the same
name as in Block 3?
17b. Has importer ever been assigned a CBP Importer Number using a name
different from that in Block 3?
Yes (List number(s) and/or name(s) in Block 17c.)
17c. If ''Yes'' to 17a and/or 17b, list number(s) and/or name(s)
18. Printed or Typed Name and Title
19. Telephone No. Including Area Code
22. Broker Use Only
Previous Editions are Obsolete
I CERTIFY: That the information presented herein
is correct; that if my Social Security Number is
used it is because I have no IRS Employer
Number, that if my CBP assigned number is used it
is because I have neither a Social Security
Number nor an IRS Employer Number, that if none
of these numbers is used, it is because I have
none, and my signature constitutes a request for
assignment of a number by CBP.
CBP Form 5106 (03/99)