A link to the Portable Document Format (PDF) of this form is provided below. The content of the form is duplicated in HTML following the PDF link.
- 1. Application for licence
- 2. Amendment(s) to field(s)
- 3. Company name
- 4. Head office address
- 5. Postal/Zip code
- 6. Name and title of contact(s)
- 7. Telephone No.
- 8. Surety bond
- 9. Government of Canada bond
- 10. Other (specify)
- 11. Name and address of guarantee company
- 12. Bond No.
- 13. Amount
- 14. Warehouse address
- 15. Postal code
- 16. Warehouse operator
- 17. Premises
- Owned by applicant
- Leased by applicant
- 18. Distance from customs office
- 19. Name of lessor
- 20. Type of goods to be warehoused
- General merchandise
- Tobacco products
- Firearms, weapons, ammunition or prohibited devices (Note: Copy of Carrier or Business Licence must be submitted with application.)
- Specific class of goods (specify) )
- 21. Cargo control document to warehouse
- 22. Canadian point(s) of entry
- 23. Mode of transportation from foreign country to Canada
- 24. Mode of transportation to warehouse
- 25. Number of bays/doors
- 26. Goods are for
I/We hereby certify that all information provided with this application is true and should I/we be granted a licence to operate a customs sufferance warehouse, I/we will conform with all the provisions of the customs and excise laws and regulations, requirements and procedures for the operation for a customs sufferance warehouse.
- Signature of applicant
Do not use this area
- Premise examined
- Meets requirements/ Does not meet requirements
- Recommended for approval / Not recommended for approval
- Authorized signature
- Approved (Licence No.) / Not approved
- Authorized signature
- For Minister of Public Safety
Note: This does not constitute a valid licence.
Field 1 Indicate with a checkmark if the application is for an original licence.
Field 2 Indicate amendments by referring to field numbers.
Field 3 The legally registered name of the company as shown on the security posted and, in the case of limited companies, as shown on the corporate seal.
Fields 4 and 5 The full mailing address of the corporate head office including the postal or zip code. This address will be used for all correspondence concerning the application, and, after authorization is granted, all correspondence concerning the operations of the company.
Fields 6 and 7 Provide the name, title, and telephone number of the person(s) who should be contacted in regards to the general operations of the company. If the address(es) differs from the head office address, provide the address(es). Use an additional page if necessary.
Field 8 Indicate with a checkmark if a surety bond from a guarantee company or financial institution is posted as security.
Field 9 Indicate with a checkmark if Government of Canada bonds are posted as security. Where an applicant has chosen to submit Government of Canada bonds, Form Y76 is to be completed and submitted with the bonds and this application. Form Y76 may be obtained from any customs office.
Field 10 Indicate with a checkmark if security other than a surety or Government of Canada bond is posted. Identify the type of security being posted, i.e., cash or certified cheque.
Field 11 When surety bonds are posted as security, provide the full, legally registered name of the guarantee company or financial institution which issued the bond. Where applicable, provide the head office address of the guarantee company or financial institution. If not known, leave blank.
Field 12 Where applicable, indicate the bond number of the surety bond.
Field 13 Provide the amount of security.
Fields 14 and 15 The full mailing address of the warehouse including the postal code.
Field 16 Indicate the name of the company operating the warehouse, if different from field 4.
Field 17 Place a checkmark in the appropriate box.
Field 18 Metres/kilometres or yards/miles.
Field 19 Provide name of lessor, if applicable.
Field 20 Indicate type of goods, i.e., general merchandise, tobacco products, spirits, firearms, weapons, ammunition, or prohibited devices, specific class of goods (CSA-LTL, household goods and personal effects, bulk and liquid products, etc.).
Field 21 Indicate type of cargo control document the goods will move on to warehouse, i.e., air waybill, rail billing, highway, or marine bill, freight forwarders' house bills.
Field 22 Indicate point(s) of entry into Canada.
Fields 23 and 24 Indicate applicable mode, i. e., air, rail, highway or marine.
Field 25 Indicate number of bays.
Field 26 Place a checkmark in the appropriate box(es).
The completed application in triplicate and supporting documentation must be submitted to the customs office having jurisdiction over the area where the warehouse is located.
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