Form CBP Form 3124E CBP Form 3124E Application for Customs Broker License Exam

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1651-0034 Exp. 07-31-2017

U.S. Customs and Border Protection

1. Applicant's Name and Address

APPLICATION
FOR
CUSTOMS BROKER LICENSE EXAM

Email Address:

19 U.S.C. 1641; 19 CFR 111.13
2. Residence Address (If different from Block 1; if same write "SAME")

3. CBP Port

4. All Applicants MUST be U.S. Citizens
One or more of the following documents may be presented to verify citizenship and identity.
U.S. passport
Certificate of Naturalization
Final adoption decree
Driver's license (identity)
5. Does the Applicant seek Accommodations under the American
Disabilities Act?
No

Yes (Explain in Block 12)

Birth Certificate
Certificate of U.S. Citizenship
Official military service record
State, federal or local government ID card

6. Is the Applicant an Officer or Employee of the United States?
No

Yes (If yes, you may not take the exam)

SECTION I
7. Date of Birth

8. Birthplace (City & State)

9. Social Security No.

10. Home Phone No.

11. Business Phone No.

12. Remarks: (In responding to questions above, include Block number. If more space is needed, continue on blank sheet of paper.)

SECTION II – CERTIFICATION
WARNING: Any misstatement of pertinent facts in this application constitutes sufficient grounds for denial of the application. If a passing score is
achieved and it is later determined that a misstatement of pertinent facts is identified, the applicant's license application will be denied.
13.

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.
Signature

Date

Privacy Act Notice: Pursuant to the requirements of Public Law 93-579 (Privacy Act of 1974), as amended, notice is hereby given in accordance with 5 U.S.C.
552a(e)(3) that the authority to collect information on CBP Form 3124E is 19 U.S.C. 1641; 5 U.S.C. 301; Reorganization plan no. 1 of 1950; Treasury
Department Order No. 165, Revised and Amended; The information, collected and contained on this application form, may be provided to those employees of
the Department of Homeland Security, CBP who have a need for the information contained herein in the performance of their duties. The information may also
be used, when deemed appropriate by the Department of Justice for its use in connection with appeals.
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- 0034. The estimated
average time to complete this application is 1 hour. 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 3124E (07/14)