Last saved by: Lisa Olson

Copyright 1995, National Customs Brokers and Forwarders Association of America, Inc. (Revised 07/04)

CUSTOMS POWER OF ATTORNEY
and
Acknowledgement of Terms and Conditions of Service
./ appropriate box:      ❑ Individual
•	Partnership
•	Corporation
•	Sole Proprietorship
•	Limited Liability Company
KNOW ALL MEN BY THESE PRESENTS: That;	✓	doing
(Full name of individual, partnership, corporation, sole proprietorship, or Limited Liability Company) (Identify)
business as a	under the laws of the State of	
(Individual, partnership, corporation, sole proprietorship, or Limited Liability Company) (Insert one)
residing or having a principal place of business at	, hereby constitutes and
appoints	, its officers, employees, and/or specifically authorized agents, to act for and
(Grantee's Name)
on its behalf as a true and lawful agent and attorney of the grantor for and in the name, place and stead of said grantor, from this date, in the United States (the "territory") either in writing, electronically, or by other authorized means, to:
Make, endorse, sign, declare, or swear to any customs entry, withdrawal, declaration, certificate; bill of lading, carnet or any other documents required by law or regulation in connection with the importation, exportation, transportation, of any merchandise in or through the customs territory, shipped or consigned by or to said grantor;
Perform any act or condition, which maybe required by law or regulation in connection with such merchandise deliverable to said grantor; to receive any merchandise;
Make endorsements on bills of lading conferring authority to transfer title; make entry or collect drawback; and to make, sign, declare, or swear to any statement or certificate required by law or regulation for drawback purposes, regardless of whether such document is intended for filing with Customs;
Sign, seal, and deliver for and as the act of said grantor any bond required by law or regulation in connection with the entry or withdrawal of imported merchandise or merchandise exported with or without benefit of drawback, or in connection with the entry, clearance, lading, unlading or navigation of any vessel or other means of conveyance owned or operated by said grantor, and any and all bonds which may be voluntarily given and accepted under applicable laws and regulations, consignee's and owner's declarations provided for in section 455, Tariff Act of 1930, as amended, or affidavits or statements in connection with the entry of merchandise;
Sign and swear to any document and to perform any act that may be necessary or required by law or regulation in connection with the entering, clearing, lading, unlading, or operation of any vessel or other means of conveyance owned or operated by said grantor;
Authorize other Customs Brokers duly licensed within the territory to act as grantor's agent; to receive, endorse and collect checks issued for Customs duty refunds in grantor's name drawn on the Treasurer of the United States;. if the grantor is a nonresident of the United States, to accept service of process on behalf of the grantor;
And generally to transact Customs business, including filing of claims or protests under section 514 of the Tariff Act of 1930, or pursuant to other laws of the territories, in which said grantor Is or may be concerned or interested and which may properly be transacted or performed by an agent and attorney;
Giving to said agent and attorney full power and authority to do anything whatever requisite necessary to be done in the premises as fully as said grantor could do if present and acting, hereby ratifying and confirming all that the said agent and attorney shall lawfully do by virtue of these presents;
This power of attorney to remain full force and effect until revocation in writing is duly given to and received by grantee (if the donor of this power of attorney is a partnership, the said power shall in no case have any force or effect in the United States after the expiration 2 years from the dates of its execution);
Grantor acknowledges receipt of	Terms and Conditions of Service governing all transactions between the Parties.
(Grantee's Name)
if the Grantor is a Limited Liability Company, the signatory certifies that he/she has full authority to execute this power on behalf of the Grantor.
IN WITNESS WHEREOF, the said	
(Full name of company)
caused these presents to be sealed and signed: (Signature)	
(Capacity)	Date:	
Witness: _,(if required)	

If you are the importer of record, payment to the broker will not relieve you of liability for Customs and Border Protection (CBP) charges (duties, taxes or other debts owed CBP) in the event the charges are not paid by the broker. Therefore, if you pay by check, Customs charges may be paid with a separate check payable to the " Customs and Border Protection" which shall be delivered to CBP by the broker. Importers who wish to utilize this procedure must contact our office in advance to arrange timely receipt of duty checks.
APPERSON PRINT MANAGEMENT SERVICES • NCBFAA-3 • WNSE. NO. 03540

INDIVIDUAL OR PARTNERSHIP CERTIFICATION
CITY	
COUNTY	' SS:
STATE	
On this	.day of	, 20	, personally appeared before me .
residing at	 , personally known or sufficiently identified to me, who
certifies that	(is) (are) the individual (s) who executed the foregoing instrument and acknowledge
it to be	free act and deed.
(Notary Public).

CORPORATE CERTIFICATION
(To be made by an officer of other than the one who executes the power of attorney)
I,	 , certify that I am the	 of
	, organized under the laws of the State of	 that
	, who signed this power of attorney on behalf of the donor, is-the	
	of said corporation; and that said power of attorney was duly signed, and attested for and in behalf of said
corporation by authority of its governing body as the same appears in a resolution of the Board of^. Directors passed at a regular meeting held on 
the	 day of	, 20	, now in my possession or custody. I further certify that the resolution is in accordance with the articles of incorporation and bylaws of said corporation and was executed in accordance with the laws of the State or Country of Incorporation.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed the seal' of said corporation, at the City of
this	day of	, 20	.
(Signature) ..	(date))