OMB NO Form: 0625-0259
Expire: December 31,2009
Application for Cement Import License
All fields are required except Customs Entry Number and those fields for products Two and Three.

Applicant Information
Company Name:
Address 1:
Address 2:
City: State: Zip:


Contact Name:
Contact Phone: Contact Fax: Contact Email:


Import/Export Information
Importer Name: Exporter Name: Manufacturer Name:

Country of Origin: Country of Exportation: Expected Port of Entry:

Expected Date of Importation (mm/dd/yyyy): Expected Date of Export (mm/dd/yyyy): Customs Entry Number (Optional):

Date License Valid From: Date License Valid Through: Date of Application:


Subregion Information
Subregion of Final Destination:
Customer Affiliation: Affiliated Unaffiliated Foreign Trade Zone Final Customer Unknown
Name:
Address 1:
Address 2:
County:
City: State: Zip:





Product 1
HTSUS Number 1:
Product Description:
Quantity: Unit: Entered Value in US (ie 50000.00):
Note: Do not use commas or $		 Unit Value: Mexican Export License #:
$

Is this entry made pursuant to the disaster relief provisions of the Agreement?


Product 2
HTSUS Number 2:
Product Description:
Quantity: Unit: Entered Value in US $: Unit Value: Mexican Export License #:

Is this entry made pursuant to the disaster relief provisions of the Agreement?


Product 3
HTSUS Number 3:
Product Description:
Quantity: Unit: Entered Value in US $: Unit Value: Mexican Export License #:

Is this entry made pursuant to the disaster relief provisions of the Agreement?


Public reporting for this collection of information is estimated to be 10 minutes per response, including the time for reviewing instructions, and completing and reviewing the collection of information. All responses to this collection of information are required, and will be provided confidentially to the extent allowed by law. Notwithstanding any other provision of law, no person is required to respond to nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Reports Clearance Officer, International Trade Administration, Department of Commerce, Room 4001, 14th and Constitution Avenue, N.W., Washington, D.C. 20230.

Before submitting this form to the Department of Commerce, you must check the box below to certify that, as a representative of the manufacturer or importer, the above information is accurate and complete to the best of your knowledge.

I certify that the above information is accurate and complete to the best of my knowledge.