216 Application for Foreign Trade Zone Activity Permit

Approved through OMB No. 1651-0029

U.S. DEPARTMENT OF HOMELAND SECURITY

1. ZONE NO. AND LOCATION (Address)

Bureau of Customs and Border Protection
APPLICATION FOR
FOREIGN-TRADE ZONE
ACTIVITY PERMIT

2. ZONE ADMISSION NO.

3. APPLICATION DATE

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 manipulation or
manufacture, a statement as to whether merchandise with one zone status is to be packed, commingled, or combined with merchandise having different 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

7.
MARKS AND
NUMBERS

8.

9.

10.

11.

DESCRIPTION OF MERCHANDISE

QUANTITY

WEIGHTS,
MEASURES

ZONE
STATUS

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

APPROVED BY FOREIGNTRADE ZONE OPERATOR

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

FTZ OPERATOR'S
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

CBP Form 216 (01/01)

PAPERWORK REDUCTION ACT NOTICE: This request is in accordance with the Paperwork Reduction Act. 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 10 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 Services Branch, Washington, DC 20229, and to the Office
of Management and Budget, Paperwork Reduction Project (1651-0029), Washington, DC 20503.

CBP Form 216 (01/01) (Back)