Form 216 Foreign-Trade Zone Activity Permit

Approved through OMB No. 1651-0029 Exp. 01-31-2010

DEPARTMENT OF HOMELAND SECURITY

1. ZONE NO. AND LOCATION (Address)

U.S.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.
7.
ZONE LOT NO.
MARKS AND
OR UNIQUE
NUMBERS
IDENTIFIER

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 U.S. 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
U.S. 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)