L55 - Application for Customs Brokers Examination

Protected when completed

Note: The information provided 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 the personal information bank, applications for customs brokers licence record CBSA PPU 006.

Please complete this form with your name as you wish it to appear on your certificate.

• Given name and Initials
• Last name
• Residential address
• Postal code
• Telephone no.
  • Residential
  • Office
  • Cell
• E-mail address(es)

I hereby apply to take the Customs Brokers Professional Examination in accordance with the Customs Brokers Licensing Regulations.

• Signature of applicant
• Date (Y/M/D)

Mail this application and a $200.00 cheque made payable to the Receiver General for Canada to:

Canada Border Services Agency
Commercial Registration (HQ)
191 Laurier Avenue West, 12^th Floor
Ottawa ON K1A 0L8

Date modified:

2013-03-08