1.
Department of the treasury
United States Custom Service
Custom form
Each one of the travelers or head of family has to provide the following information (only on form
per family)
1. LAST NAME ……………………………………………..
2. NAME……………………………………………………..
3. DATE OF BIRTH: DAY……. MONTH …….. YEAR………
4. NUMBER OF FAMILY MEMBERS TRAVELING WITH YOU ………………………..
5. US ADDRESS………………………………………………………………………………
CITY………………………………………… STATE…………………………………….
6. PASSPORT ISSUED IN …………………………………………………………………..
7. PASSPORT NUMBER ………………………………..
8. I AM A ………………………….. CITIZEN
9. AIRLINE FLIGHT…………………………………………
10. THE PURPOSE OF MY TRIP IS BUSINESS: YES…… NO……
11. I/WE ARE BRINGING
A) FRUITS, FOOD, VEGETABLES, INSECTS YES…… NO ……. SPECIFY………
B) MEALS, ANIMALS, FARM PRODUCTS YES…… NO ……. SPECIFY………
12. I/WE ARE CARRYING CURRENCY OR MONETARY INSTRUMENTS EQUIVALENT TO
………………………………………………………………
13. DEPARTURE DATE: …………………..
14. TIME STAYING IN THE TERRITORY…………………………..
SIGNATURE: ……………………………………… DATE………………………………..