Cbp Form 4811 - Us Customs And Border Protection
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1DEPARTMENT OF
I request that: (Mark only one code )
HOMELAND SECURITY
10
Bills, Refunds and
40
Bills and Notices
34
Checks and Notices
Notices of Liquidation
U.S. Customs and
Border Protection
20
Checks for Refunds or
23
Bills and Checks
Drawback only
SPECIAL
30
Bills Only
24
Notices of Liquidation only
be addressed to the undersigned in care of the agent whose Importer Number is shown below
ADDRESS
whenever it appears as Reference Number on an Entry Summary (CBP 7501) for which I am (my
organization is) the Importer of Record.
NOTIFICATION
Agent's Name _______________________________________ Agent's Number ________________
(Show hyphens)
My (organization's) Importer No.
(Show hyphens)
Principal
Note:
A Report of Importer
Member of Firm
Number (CBP 5106) must be
______________________________________________ ________
_____________of the Corp.
on
file
for
each
Importer
(Signature)
(Date)
(Title)
Number
appearing
on
this
CBP Form 4811 (10/01)
form.
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