Form 216 Application for Foreign-Trade Zone Activity Permit

OMB Control Number: 1651-0029; Expiration Date: 06/30/2015

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 (05/10)

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 1651-0029. The estimated
average time to complete this application is 10 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 216 (05/10)