Form 3499 Application and Approval to Manipulate, Examine, Sample

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection

APPLICATION AND APPROVAL
TO MANIPULATE, EXAMINE, SAMPLE OR TRANSFER GOODS
19 CFR 19.8, 19.11, 158.43

Form Approved
OMB No. 1651-0006
Exp. 09-30-2012

1. GOODS CONSIGNED TO (Name)

2. GOODS EXPORTED FROM

3. PORT/PORT CODE AND DATE OF APPLICATION

4. LOCATION OF GOODS

5. CARRIER OR SHIP (Name)

6. BILL OF LADING OR CBP 7512 NO.

7. IS AREA BONDED?

8. ENTRY INFORMATION

Number:

YES

NO

Warehouse

Consumption

Date:

PERMISSION IS REQUESTED TO: (Describe the complete operation to be performed under CBP supervision on the goods listed below):

9. MARKS AND NUMBERS

10. DESCRIPTION

FOR CBP USE ONLY
11. MANIPULATED VALUE

12. SIGNATURE OF APPLICANT
APPROVED
13. DATE

14. SIGNATURE AND TITLE OF APPROVING CBP OFFICER

See Page 2 of form for Paperwork Reduction Act Notice. Customs and Border Protection Officers Report on Reverse

CBP Form 3499 (10/95)

CUSTOMS AND BORDER PROTECTION OFFICER'S REPORT

Date:

MANIPULATION COMPLETED AS REQUESTED: When goods are repacked the CBP (warehouse) officer will report
hereon the marks and numbers of packages repacked and the marks and numbers of packages and the weights or
guage of same after repacking.

(CBP Officer and Title)

PAPERWORK REDUCTION ACT STATEMENT: An agency may not conduct or sponsor an information collection and a person is not
required to respond to this information unless it displays a current valid OMB control number and an expiration date. The control number for
this collection is 1651-0006. The estimated average time to complete this application is 6 minutes. If you have any comments regarding the
burden estimate you can write to U.S. Customs and Border Protection, Office of Regulations and Rulings, 799 9th Street, NW., Washington
DC 20229.

CBP Form 3499 (10/95)