Form 4455 Certificate of Registration

Form Approved. OMB No. 1651-0010
Exp. 08-31-2009
NO.

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection
CERTIFICATE OF REGISTRATION
(NOTE: Number of copies to be submitted varies with type of transaction.
Inquire at Port Director's office as to number of copies required.)

19 CFR 10.8, 10.9, 10.68,
148.1, 148.8, 148.32, 148.37
VIA (Carrier)

DATE

B/L or INSURED NO.

NAME, ADDRESS, AND ZIP CODE TO WHICH CERTIFIED FORM IS
TO BE MAILED (If Applicable)

ARTICLES EXPORTED FOR:
ALTERATION*
REPAIR*
USE ABROAD
REPLACEMENT

PROCESSING*
OTHER, (specify)

* NOTE: The cost or value of alterations, repairs, or processing
abroad is subject to CBP duty.
LIST ARTICLES EXPORTED
Number
Packages

Kind of
Packages

Description

DATE

SIGNATURE OF OWNER OR AGENT (Print or Type and Sign)

The Above-Described Articles Were:
DATE

EXAMINED
PORT

SIGNATURE OF CBP OFFICER

DATE

LADEN under my supervision
PORT

SIGNATURE OF CBP OFFICER

CERTIFICATE ON RETURN
Duty-free entry is claimed for the described articles as having been exported without benefit of drawback and are returned unchanged except as noted: (use
reverse if needed)

SIGNATURE OF IMPORTER (Print or Type and Sign)

DATE

NOTE: Certifying officers shall draw lines through all unused spaces with ink or indelible pencil.
Paperwork Reduction Act Notice: This request is in accordance with the Paperwork Reduction Act. The information to be provided is submitted by importers/
exporters. Completion of this form is mandatory and to your benefit. The estimated average burden associated with this collection of information is 3 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 U.S. Customs and Border Protection, Information Services Branch, Washington, DC 20229, and to the Office of Management and
Budget, Paperwork Reduction Project (1651-0010), Washington, DC 20503.

CBP Form 4455 (06/00)