U.S. Principal Party in Interest (USPPI)
Name:
Address:
City:
Country/Territory:
State/Province:
Postal Code:
Contact Telephone:
Contact E-Mail:
USPPI EIN (IRS) or ID No.
Parties to Transaction:	Related Non Related

Ultimate Consignee
Name:
Address:
City:
Country/Territory:
State/Province:
Postal Code:

Intermediate Consignee
Name:
Address:
City:
Country/Territory:
State/Province:
Postal Code:

Shipment Information
Transportation Reference Number:	Leave blank to automatically create.
Date of Exportation:	Saturday, November 07, 2009Sunday, November 08, 2009Monday, November 09, 2009Tuesday, November 10, 2009Wednesday, November 11, 2009Thursday, November 12, 2009Friday, November 13, 2009
Point (State) of Origin or FTZ No.:
Country of Ultimate Destination
Loading Pier:
Method of Transportation:	Air Ocean Truck Rail
Exporting Carrier:
Port of Export:
Port of Unloading:
Containerized:	Yes No
Carrier Identification Code:
Shipment Reference Number:
Entry Number:
In Bond Code:
Hazardous materials:	Yes No
Routed Export Transaction:	Yes No

If additional item space is necessary to complete this form, please enter the number below:
Number of additional items:

Description
D/F/M	Scd B Number	Description	Quantity	Shipping Weight (KILOS)	VIN/ Product Number	Value (USD omit cents)
D F M
D F M
D F M
D F M
D F M
D F M
D F M
D F M
D F M
D F M

Authorization
Validated License Number	Enter Number or NLR
ECCN
Authorized Officer or Emp.
The exporter authorizes the forwarder named above to act as forwarding agent for export control and customs purposes.

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