Form 6478 Application for CBP Approved Gaugers and Accredited Labo

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection

Form Approved OMB No. 1651-0053
EXP. 06-30-2016

APPLICATION FOR CBP APPROVED
GAUGERS AND ACCREDITED LABORATORIES
19 CFR 151.12; 151.13

INSTRUCTIONS: Submit application, including all additional continuation sheets (if required) and attachments in duplicate
to the Executive Director, Laboratories and Scientific Services Directorate.
SECTION I - APPLICANT
1. Applicant's Name and Principal Office Address and indicate fictitious name (if applicable)

2. Type of License Applied For
Laboratory

Gauger

Laboratory/Gauger

4. Have you ever applied for a CBP accreditation/approval?

3. CBP Port and Port Code

No
5. Has the applicant (or any officer, member, or principal thereof)
ever had an accreditation/approval suspended, refused,
revoked, or cancelled?
No
7. Date of Birth

Yes (Explain in Block 16)
8. Birthplace (City & State)

6. Is the applicant (or any officer, member or principal thereof)
an officer or employee of the United States?
No

9. SSN

Yes (Explain in Block 16)

Yes (Explain in Block 16)

10. Telephone Numbers:
Home Business Email (Business) -

Ext.

11. U.S. Citizenship
Natural Born

Naturalized - Give Date and Place >

12. Have you ever been arrested, charged, convicted of or
forfeited collateral for, any felony, misdemeanor, or other
violation?
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You may omit: 1. traffic violations for which you paid a fine of $250
or less; 2. any incident which happened before your 16th birthday.
All other incidents must be included, even though the case records
were expunged or suppressed under a rehabilitation program, or
you were sentenced under a State statute which provides that you
No
Yes (Explain in Block 16)
need not report the incident when apply for employment, a license,
etc.
13. Address of principal place of business (if different from Block 1: is same, write "Same")
14. In the last 5 years, have you, or a company ever which you exercised some control, filed for bankruptcy, been declared bankrupt,
been subject to a tax lien, or had legal judgement rendered against you for a debt?
No

Yes (Explain in Block 16)

15. List names of all Officers and Directors

16. Remarks/Additional Information (In responding to questions above, include Block number. If more space is needed
use blank sheet.

CBP Form 6478 (10/14)

SECTION II - CORPORATION
17. Date Corporation was organized

18. State Where Organized

19. List each person who will be authorized to sign/approve analysis report and/or gauging reports:
Name
Title
Qualifications

20. Attachments
If a corporation, a copy of articles of incorporation or
association
Detailed statement of ownership and any partnerships,
parent-subsidiary relationships, or affiliations with any other
domestic or foreign organization, including, but not limited to,
import, other commercial laboratories, producers refiner, CBP
brokers, or carriers

A listing of each commodity group for which laboratory
accreditation is being sought and, if methods are being
submitted for approval with are not specifically provided for in a
Commodity Group Brochure and the CBP Laboratory Methods
Manual, a listing of such methods.

A statement of financial condition (i.e., statement from a
Certified Public Accountant or notarized statement)

A listing by commodity group of each method according to
its CBP Laboratory Method Number for which the Laboratory is
seeking accreditation; (section 151.12(d) or CBP website
http://www.cbp.gov/about/labs-scientific-svcs

A complete description of the applicant's facilities, instruments,
and equipment

An expressed agreement to be bound by required obligation
(see commercial gauger and laboratory agreement)

An expressed agreement that if notified by CBP of pending
accreditation/approval to execute a bond in accordance with 19
CFR, part 113, CBP Regulations, and submit it to the CBP port
nearest to the applicant's main office. The limits of liability on the
bond will be established by the CBP port in consultation with the
Executive Director. In order to retain CBP accreditation/
approval, the laboratory/gauger must maintain an adequate
bond, as determined by the Port Director.

A non-refundable prepayment equal to 50 percent of the fixed
accreditation/approval fee, as published in the Federal Register and
CBP Bulletin, to cover preliminary processing costs. Further, the
applicant agrees to pay CBP with in thirty (30) days of notification of
preliminary accreditation/approval the associated charges assessed
for accreditation/approval (i.e., those charges for actual travel and
background investigation costs, and the balance of the fixed
accreditation/approval fee.)

SECTION III - CERTIFICATION (All Applicants)
WARNING: Any misstatement of pertinent facts in this application constitutes sufficient grounds for denial of the application.
21. NAME OF PERSON SIGNING APPLICATION
I

, Certify that the statements contained in the foregoing application and supporting

attachments thereto are true and correct to the best of my knowledge and belief. Written notice of any change in my mailing address,
and business connection, or the name and style under which I conduct my business will be given to the Commissioner of U.S.
Customs and Border Protection.

Signature

Date

Privacy Act Notice: Pursuant to the requirements of Public law 93-579 (Privacy Act of 1974), notice is hereby given that the authority to
collect information is 5 U.S.C. 301, 19 CFR 151.12 and 19 CFR 151.13. The principal purpose for collecting the information is to enable
CBP to conduct a background investigation and thereby determine whether the applicant processes the overall competence,
independence, and character required for CBP accreditation/approval. The information collected and contained in the applicant's file
may be provided to those employees of CBP who has a need for the records in the performance of their duties. The information may
also be used, when deemed appropriate, in a proceeding to revoke or suspend CBP accreditation/approval. Disclosure of all
information requested is voluntary; however, failure to disclose some or all of this information may result in CBP's inability to conduct
the required background investigation.

CBP Form 6478 (10/14)