Customs Application Form

CUSTOMS APPLICATION FORM

Whereas - Recitals

WHEREAS Applicant Name: (hereinafter "Applicant") intends to import or export goods and requests customs brokerage and clearance services in accordance with applicable customs laws and regulations;

WHEREAS Customs Broker Name: (hereinafter "Broker") is licensed and authorized to act as a customs broker and to prepare and file customs entry documentation on behalf of the Applicant;

WHEREAS the parties desire to record the Applicant's customs declaration, the scope of brokerage services to be provided, payment terms, and the mutual covenants contained in this Application and Agreement.

Applicant and Entity Information

Corporation Individual Partnership Other

Scope of Work

The Broker will perform the following services in respect of the shipment(s) described in this application. Applicant authorizes Broker to prepare, sign and file required customs documents and to act as agent for customs clearance:

Customs Shipment Details

Goods Description and Valuation

Provide each commodity line below. Attach additional sheets if necessary. The Applicant certifies that the descriptions, quantities and values are accurate and complete.

Payment Terms

Applicant agrees to pay Broker fees, duties, taxes and any disbursements incurred in connection with customs clearance in accordance with the terms below.

All fees are due immediately upon billing unless otherwise agreed in writing. Applicant remains responsible for duties, taxes and penalties assessed by customs authorities regardless of any advances by Broker.

Term and Termination

This Agreement is effective as of the date of signature and shall continue until the completion of the clearance services for the shipment(s) identified, unless earlier terminated as set forth below.

Either party may terminate for cause upon written notice if the other party materially breaches any obligation and fails to cure within the notice period. Termination does not relieve Applicant of obligations to pay for services rendered and costs incurred prior to termination.

Confidentiality

Each party shall keep confidential all non-public information received from the other party in connection with this Agreement and shall not disclose such information except as required by law, regulation, or as necessary to perform the services described herein. Confidential information does not include information that is or becomes publicly known through no breach of this Agreement.

Authorizations and Declarations

The Applicant certifies under penalty of perjury that the information supplied on this form is true, correct and complete to the best of Applicant's knowledge. Applicant authorizes Broker to prepare and sign customs entries, to make declarations, to pay duties, taxes and charges on Applicant's behalf, and to obtain and receive information from carriers, freight forwarders, and governmental authorities necessary to effect clearance.

Authorization Granted: I hereby grant Broker power of attorney to act on my behalf for the purposes set forth above.

Warning: Falsification of customs documents is a serious offense and may result in civil and criminal penalties, including seizure of goods, fines, and prosecution.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the jurisdiction specified below. Any claim or dispute arising out of or relating to this Agreement shall be determined in the courts of the designated jurisdiction unless otherwise agreed in writing.

Entire Agreement

This Application and Agreement, including any schedules or attachments executed by the parties, constitutes the entire agreement between the parties with respect to customs brokerage and clearance for the referenced shipment(s) and supersedes all prior negotiations, representations or agreements, whether written or oral.

Additional Information / Attachments

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