Form Application for International Carrier Bond 301-3


Application for Customs Form 301-3
International Carrier Bond (CFR113.64)

Applicant is (select one):

If selected, define other:


Applicant Name (Principal):


Principle's Physical Address line 1:

Street:

City, State:

Zip Code:


Principle's Physical Address line 2:

Street:

City, State:

Zip Code:


Mailing Address (if different), line 1:

Street:

City, State:

Zip Code:


Mailing Address line 2:

Street:

City, State:

Zip Code:


Principle's Phone Number:

Fax Number:


Are there any additional unincorporated divisions, trade names, subsidiaries or importer numbers for your company?

If so, please attach a complete listing with names, addresses and importer numbers/Customs assigned numbers.


Description of Applicant's Operations:

Importer/Customs Assigned Number:

How long in business?


Principle Owner's Name: (If Partnership or LLC list all owners on separate sheet):

Address line 1:

Street:

City, State:

Zip Code:

Address line 2:

Street:

City, State:

Zip Code:

U.S. Citizen?

Spouse's Name:

Is there an active bond on file in ANY port? If so, list which port, Customs assigned bond number, renewal date and attach a copy of the bond.

Port:

Bond #:

Renewal Date:

Desired Bond Amount:

Desired Effective Date of Bond:

Would you like a 1 or 3 year (pre-paid) billing plan? (3 year plan receives a 20% discount on years 2 & 3):

Underwriting Questions (required for all applicants):

1) Does the Applicant have any other Surety bonds in force?

2) Has another Surety Company Declined to write this or any previous bond?

3) Have you ever had a bond involuntarily terminated or cancelled?

4) Has there ever been a claim or legal action against any bond executed on your behalf?

5) Do you or any of your companies have any pending lawsuits, unsatisfied judgments or liens?

6) Have you or any of your companies declared bankruptcy or become insolvent?

7) Have you or any of your companies been the subject of any legal or administrative proceedings resulting in disciplinary action?

8) Have you ever been convicted of a felony?

9) Has the Applicant continuously been in business under the current name and ownership for at least 3 years?

10) If the Applicant is a business, has it been in business at the same location for at least 3 years?

11) If the Applicant is an individual, have you resided at your current address for at least 3 years?

(If you answered Yes to any of the above questions, please attach an explanation.)

Attach a copy of the last fiscal year-end financial statements. If 6-months or older, attach interim statements also.


If the principle is a new business, (less than 3 years in operation) also attach personal financial copy attached statement(s) for owner(s).



IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, AND DENIAL OF BENEFITS.

Signature:

(By typing your name, you are officially signing this form)

Date:

Print name and title here: