L53 - Application for a Customs Brokers Licence

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PROTECTED A when completed

NOTE: The information on this form is collected for the purpose of maintaining a record of applications and is protected under the provisions of the Privacy Act. The form is stored in personel information bank, Applications for Customs Brokers Licence record # RCC PPU O25.

This form is to be completed by the qualified officer

This application is for a licence to transact business at:

Customs Office Code(s)

Reason for filing this application:

Name in which business will be transacted

Business Number

Legal name if different from above

E-Mail address

Street address of brokerage office

Telephone number

Facsimile number

Have you attached the required $50,000 security?

Please indicate if your company is:

Please indicate below all directors and partners (given name, initials, surname) (attach L60 questionnaires) - Attach an additional page if required.

Name of qualified officer, individual or partner

Date of qualification

Business address of qualified officer

Telephone number

Facsimile number

Declaration by the qualified officer

I declare that, to the best of my knowledge, the information given in this application is true. I make this declaration knowing it is of the same importance as if made under oath and by virtue of The Canada Evidence Act. I agree to advise the chief officer of customs of any change in ownership, partners, directors or qualified officers as well as change to the name, address and anyother things affecting the licence if granted. I hereby authorized the CBSA to consult with bankers or other financial institutions regarding the financial situation of the applicant, and I undertake to provide the Agency with a copy of a business opening statement or of the most recent audited profit and loss financial statement and balance sheet when deemed necessary by the CBSA to support this application for a customs broker licence. I will fulfil all the duties and obligations of a custom's broker in accordance with the Customs Act and the Regulations established by it. I hereby authorized the release, by the custodian thereof, of any information required by the CBSA, that is neccessary in the determination of my suitability to become a licensed customs broker.

Signature of qualified officer


Do not use this area

This table is to be completed by the region prior to forwarding to Broker Licensing

The incorporation documents are attached (if applicable)

Amendments to incorporation documents are attached (for changes of legal business name)

Security is attached

Minutes/Resolutions of shareholders meetings (for appointment of directors)

Minutes/Resolutions of meetings of board of director (for appointment of qualified officer)

Financial documents are attached

L60 questionnaires and investigation are attached (for appointment of directors, qualified officers and qualified persons)

Approval of the Regional Director of Customs Border Services

Please check only one box

Signature of Manager Commercial Registration (HQ)

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