Bond Application Instructions - Old Dominion …

1 1156 BOWMAN ROAD SUITE 200 MT. PLEASANT, SC 29464 PHONE: (843) 375-2003 FAX: (843) 416-1199 bond Application Instructions Section I Principal/Indemnitor Information Company Name: Complete company name as registered in home state Company Type: Complete as registered in home state Address: Physical Address Importer Contact Name: Company Officer responsible for Import Dept Previous Surety: If a continuous bond is/was in place: name the surety on that bond Credit: Credit given by Broker to pay entry fees, etc prior to receiving payment from the Principal Yes or NO Questions: Answer each question.

2 Give explanation for any YES answers. Section II Customs Related Information Importer Number: IRS #, Social Security #, or Customs Assigned # Must provide the number registered with the State or with Customs to conduct business. Previous Importer Number: List any # applicant conducted business under prior to the above listed number bond Type-STB: Single Transaction bond bond Type-CTB: Continuous Transaction bond bond Amount: STB is Value, plus duties & fees. CTB is 10% of Value, minimum of $50,000 Effective Date: Date bond will be effective Activity Code: Choose one activity that the bond will be issued to cover Entry Type: Choose the type of entry Custodial Type: If applying for a Custodial bond (entry activity 2), please indicate which activities have been approved by USC Section III Merchandise Information Description Line: Detailed information about commodity, especially if STB Country of Origin & Port of Entry are essential FDA: Yes or No must be checked for each question Value of Merchandise: Invoice Value.

3 If a CTB, please complete last & current year information. Duties & Taxes: Total of any duties, taxes, and fees assessed by USC. If a CTB, please complete last & current year information. AD/CVD: List margin as determined by US Department of Commerce Duties/Taxes Paid: Check appropriate Payment Method Customs Certification: Printed Name & Title, Date, and Signature required Signature of Indemnitor: Printed Name & Title, Date, and Signature required Every line must be completed. All information is essential. Bolded Lines must be completed by the Principal. Web Merlin Signature scanning template Atlanta | Boston | Charleston | Chicago | Houston | Los Angeles | Miami | New York | San Francisco | Seattle | Toronto FORM # A REV 2012/05/07 Scanning Instructions 1.

4 Print this template and sign in the box. 2. Scan this template in and either email to or open with an imaging Application and crop to 138x38 pixels. 3. Save image to a location that will be easy to locate. ( , your desktop) or 4. Print this template, sign in the box and fax to your local Avalon office. 5. Please provide the mandatory information below: Contact name: Title: (CBP will only accept signatures from company officers, , President, Vice President, Corp. Treasurer, Corp. Secretary, CEO, CFO, COO, etc.) Company name: Address: City: State: ZIP: Phone: Fax: Email: Please provide access to: Single Entry Bonds Single ISF Appendix D Continuous Bonds bond Tools Reports Avalon Risk Management general Agent for the Sureties it Represents Great American Alliance Insurance Company, Cincinnati, Ohio Customs bond Application & Indemnity Form B100 Rev.

5 2015/01/09 Return completed Application to: Customs Broker Name: Filer Code: Phone: Fax: Email: Important: Applicant should complete both sides and sign where noted. Return completed applications to or fax to (847) 700-8117. The surety may require financial statements and/or additional information to approve the bond (s) upon request. Applicant/Principal/Indemnitor Information Company Name: DBA or Trade Name (if any): Individual/Sole Proprietorship. Corporation. State/Country of Incorporation: general Partnership.

6 Please include names of all partners under separate cover. Limited Partnership. If so, CBP may require complete copy of partnership agreement. Physical Address: City: State/Province: Postal Code: Country: If foreign, service of process: Importer Number (FEIN, CBP Assigned or SS#): SCAC Code (if applicable): Years in Business: Does Applicant participate in any of these CBP Programs?

7 Importer Self Assessment Trusted Trader C-TPAT Tier 2 or 3 Other: Importer Contact Name: Title: Phone: Fax: Email: Is credit extended? Yes No If yes, how much credit is extended? Applicant has been a client of the broker since (year): Are there any additional trade names and/or unincorporated divisions to be included on the bond ?

8 Yes No If yes, attach complete list. Are there other Applicants to be included as co-principals on the bond ? Yes No If yes, complete separate Application for each. Does Applicant participate in any of the following: Please note answers for all items and if yes, please provide additional information as requested: Yes No Periodic Monthly Statement? If yes, an additional surcharge may apply and financial statements may be required. Yes No Reconciliation program? If yes, a rider to the bond is required and additional premium shall apply. Yes No Importations to the Virgin Islands? If yes, a rider to the bond is required. Yes No Defer taxes on imports for tobacco, spirits and/or other commodities?

9 Do any of the following conditions apply? Yes No If yes, check any that apply below and provide further details on a separate page. Applicant and/or Partner/Officer of Applicant has previously filed for bankruptcy or is currently in bankruptcy proceedings. A surety has previously paid Customs bond claim(s) on Applicant s behalf and/or Applicant is aware of pending Customs claims. CBP has previously suspended Applicant s immediate delivery privileges and/or Applicant is currently sanctioned by CBP. Applicant and/or Partner/Officer has been investigated by CBP for fraud or negligence and/or is currently involved in an investigation. bond and Merchandise Related Information Single Entry Continuous bond Amount: $ Aggregated bond Amount: $ Effective Date: Activity Code: 1-Importer 1A-Drawback 2-Custodial 3-International Carrier 3A-International Traffic 4-FTZ 5-Gauger 6-Wool & Fur 7-B/L 8-Copyright 9-Neutrality 10-Court Costs 11-Airport Security Customs Area 12-ITC 14-IBEC 15-IPR 16-ISF (Importer Security Filing) Custodial Type: Bonded Carrier Bonded Warehouse Container Freight Station Bonded Cartmen AMS Filings International Carrier Type: Ocean Vessel AMS Filings Aircraft ISF Type: For a single ISF-D bond or Unified filing, what is.

10 (1) the ISF Filing Date? (2) Vessel Departure Date? Entry Type(s): general Merchandise TIB Warehouse Auto (DOT) FDA Chapter 98 GSP/CBI AD/CVD* *Please provide Avalon s AD/CVD questionnaire if merchandise is subject to antidumping and/or countervailing. Description of Merchandise: Country of Origin: Port of Entry: Is FDA Merchandise Subject to Automatic Detention? Yes No Is FDA Merchandise Restricted? Yes No Value of Merchandise: Last Year: $ Estimated current year: $ Duties, Taxes and Fees: Last Year: $ Estimated current year: $ Duties/Taxes Paid: With Entry With Entry Summary Via ACH payment Customs Certification, Indemnity Agreement and Collateral Policy I certify that the factual information contained in this Application is true and accurate and any information provided which is based upon estimates is based upon the best information available on the date of this Application .