Shipper/Exporter Name:
Address:
City/State/ZIP:
Tel:
Fax:
Contact:
EIN No.
Ultimate Consignee:
Name:
Address:
City/State/ZIP:
Tel:
Fax:
Contact: |
Document:Date: Export References:
Insurance: Yes_____ No_____
Insurance Value (USD):___________
Intermediate Consignee
(Customs Broker/Bank/Etc):_____________
|