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A link to the Portable Document Format (PDF) of this form is provided. The content of the form is duplicated in HTML below.
Protected A when completed
The information you provide in this document is collected under the authority of the Customs Act – section 95 for the purpose of administering the Canada Border Services Agency (CBSA) Export Program. The information may be disclosed to internal and external Government of Canada bodies for the purposes of enforcement, safety, security, statistics and intelligence. You have the right to access and to make corrections to your personal information under the Privacy Act, Section 12. The information collected is described within `Information about Programs and Information Holdings 2018' under the Personal Information Bank Export Program CBSA PPU 1103 which is detailed within the Information about Programs and Information Holdings 2018. Should you have concerns about the CBSA's handling of your personal information you have a right to file a complaint with the Privacy Commissioner of Canada.
1. Application date
2. Company name
3. Please select the applicable business type(s)
- Customs Service Provider
If a customs service provider is completing the form, the service provider information in fields 4, 5 and 6 must be completed.
4. Customs service provider name
5. Licence no.
6. Authorization ID
Operating unit information
Please complete for each participating subsidiary or location.
7. Operating name (if different than name stated above)
8. Business no.
The exporter's BN must be obtained from the Canada Revenue Agency by calling 1-800-959-5525.
City, province/state, country
10. Contact name
12. Telephone no.
13. E-mail address
14. Authorized signature
For government use only
The licence no is that of the person completing the form.
Exporter's authorization no.
Once completed, save and send form by email to: firstname.lastname@example.org
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