CBP Form 216

Approved through OMB No. 1651-0029.

U.S. DEPARTMENT OF HOMELAND SECURITY
Bureau of Customs and Border Protection

1. ZONE NO. AND LOCATION (Address)

APPLICATION FOR
FOREIGN-TRADE ZONE
ACTIVITY PERMIT
Any data typed after screen scrolls will not print.

3. APPLICATION DATE (mm/dd/yyyy)

2. ZONE ADMISSION NO.

19 CFR 146.52, 146.66
4. TYPE OF ACTIVITY FOR WHICH PERMIT REQUESTED
Manipulate

Manufacture

Exhibit

Destroy

Temporary Removal

5. FULL DESCRIPTION OF THE ACTIVITY (Include designation of the exact place in zone where the operation is to be performed and, in the case of a proposed manip ulation or
manufacture, a statement as to whether merchandise with one zone status is to be packed, commingled, or combined with merchandise having diffrent zone status. If additional
space required, attach separate sheet. If first application for manufacturing of this kind, state whether Foreign-Trade Zones board has occurred in proposed operation.)

6.
ZONE LOT NO.
OR UNIQUE
IDENTIFIER

8.

9.

10.

11.

DESCRIPTION OF MERCHANDISE

QUANTITY

WEIGHTS,
MEASURES

ZONE
STATUS

7.
MARKS AND
NUMBERS

If any merchandise is to be manipulated in any way or manufactured, I agree to maintain the records provided for in sections 146.21(a), 146.23, and
146.52(d) of the Customs Regulations and to make them available to CBP officers for inspection.
12. APPLICANT FIRM NAME

(This is a mandatory field)

APPROVED BY
FOREIGN- TRADE ZONE

13. BY (Signature)

14. TITLE

15. BY (Signature)

16. TITLE

PERMIT
The application made above is hereby approved and permission is granted to manipulate, manufacture, exhibit, destroy, or temporarily removed, as
requested, on condition that the applicable regulations are complied with and the records required to be maintained will be available for inspection.
17. PORT DIRECTOR OF CBP: By (Signature)

18. TITLE

19. DATE

(mm/dd/yyyy)

FTZ OPERATOR'S RETURN
20. TO THE PORT DIRECTOR OF CBP:
I certify that the goods described herein have been disposed of as directed except as noted below.

21. FOR THE FTZ OPERATOR: (Signature)

22. TITLE

23. DATE

(mm/dd/yyyy)

CBP Form 216 (6-03)

PAPERWORK REDUCTION ACT NOTICE: This request is in accordance with the Paperwork Reduction Act of
1995. We ask for the information in order to carry out the laws and regulations administered by the Bureau of
Customs and Border Protection and Foreign-Trade Zones Board. These regulations and forms apply to
importers/exporters to ensure that they are complying with these laws. It is mandatory. The estimated average
burden associated with this collection of information is 17 minutes per respondent depending on individual
circumstances. Comments concerning the accuracy of this burden estimates and suggestions for reducing this
burden should be directed to Bureau of Customs and Border Protection, Information Service Branch, Washington, DC
20229, and to the Office of Management and Budget, Paperwork Reduction Project (1651-0029), Washington, DC
20503.

CBP Form 216 (6-03)