1. Exporter (Name, address, phone# and Zip code)
1b. Exporter's EIN (IRS) No.
2. Date of exportation
3. Transportation reference no.
4a. Ultimate consignee (Name and Address)
Service
Port to Port
Port to Door
Cat's Runner
Door to Port
Door to Door
Charge
Freight
Origin Cost
Duty & Tax
Customs Clearance
5a. Forwarding agency
Yamato Transport U.S.A., Inc.
6. Point of origin FTZ no.
7. Country of ultimate destination
8. Loading pier / terminal
9. Method of transportation
14. Carrier identification code
15. Shipment reference no.
10. Exporting carrier
11. Port of export
16. Entry number
17. Hazardous materials
Yes
No
12. Port of unloading
13. Containerized
Yes
No
18. In bond number
19. Routed export transaction
Yes
No
Declared value for carriage
$
Insurance required
Yes
No
Amount of insurance
$
Mode
Air
Ocean
Direct
Consol
20. Schedule B destination
21. D/F
or M
22. Schedule
number
23. Quantity
schedule B units
24. Shipping
weight(Kg)
25. Vin/Product No.
Vehicle title No.
26. Value
(US$, Omit cents)
Selling price or cost if not sold.
27. License No./License exception Symble/Authorization
28. Econ (When required)
29. Duly authorized officer or employee
Date (M/D/Y)
Documents enclosed / Special instructions
30. I certify that all statements made and all information contained herein are true and correct and that I have read and understand the instructions for preparation of this document, set forth in the "Correct Way to Fill Out the Shipper's Export Declaration." I understand that civil and criminal penalties, including forfeiture and sale, may be imposed for making false or fraudulent statements herein, failing to provide the requested information or for violation of I.S. laws on exportation (13 Us.S.C Sec. 305; 22 U.S.C Sec. 401; 18 U.S.C Sec. 1001; 50 U.S.C. App. 2410).
Export shipments are subject to inspection by U.S. Customs Service and / or Office of Export Enforcement.
Name / Title
Signature
e-mail address
Tel#
Date (M/D/Y)