THE JAMAICA CUSTOMS AGENCYAPPLICATION FOR INDIVIDUAL CUSTOMS BROKERS LICENCEFOR AN APPLICANT ISSUED WITH A PROVISIONAL LICENCE AND WHO HAS COMPLETED A ONE YEAR ARTICLED PERIOD AND SUCCESSFULLY COMPLETEDTHE CUSTOMS BROKER’S TRAINING & ASSESSMENT AS REQUIRED BY THE BOARD
1. NAME OF APPLICANT:

2. TITLE:FIRST NAME:

Mr.
Mrs.
Ms.

MIDDLE NAMES:

3. DATE OF BIRTH

4. COUNTRY OF RESIDENCEDD / MM / YYYYSURNAME:
5. HOME ADDRES OF APPLICANT:

6. MAILING ADDRESS IF DIFFERENT FROM ABOVE:

7. POLICE RECORD – NO. & ISSUE DATE:

8. TRN:9. T.C.C.:

10. HOME TELEPHONE:

11. BUSINESS TELEPHONE

12. CELLULAR TELEPHONE

13. EMAIL ADDRESS 1:

14. EMAIL ADDRESS 2:

15. E-MAIL ADDRESS:

16. FACSIMILE NUMBERS:

17. NAME IN WHICH BUSINESS IS OR WILL BE OPERATED:

18. BUSINESS REGISTRATION NO.:

19. BUSINESS ADDRESS:

20. BUSINESS TRN:

22. BUSINESS TELEPHONE NUMBERS:

23. BUSINESS E-MAIL ADDRESS:

21. BUSINESS TCC NUMBER:THE APPLICANT SHALL ANSWER THE FOLLOWING MANDATORY QUESTIONSANSWERS24.

Are you the subject of any proceedings of a disciplinary or criminal nature or have you been notified of any impending
proceedings or of any investigations which might lead to such proceedings?

YESNO

25.

Have you ever been charged with or convicted of any criminal offence particularly relating to dishonesty, fraud, financial crimes
or other criminal act?

YES

NO

26.

Do you suffer from any physical or mental disability that would prevent you from properly carrying on business as a customs
broker?

YES

NO

27.

Have you ever filed for bankruptcy or adjudged bankrupt by any relevant authority?

YES

NO

28.

PLEASE NOTE: IF ANY ANSWER(S) AT QUESTIONS 24 TO 27 IS YES, STATE THE CIRCUMSTANCES BELOW.

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29.

DECLARATION BY APPLICANT:I …………...………………………………………………………………………………………………………………
(FULL NAME OF APPLICANT)
do solemnly declare that I am not an undischarged bankrupt person, neither am I suffering from any physical or mental disability and that I am in no such way hinderedfrom properly carrying on business as a customs broker. I do further solemnly declare that the information contained in this application is true to the best of myknowledge and belief and I make this solemn declaration conscientiously believing it to be true and knowing that it is of force and effect as if made under oath and by
virtue of the Voluntary Declaration Act, and I hereby agree to inform the Commissioner of Customs forthwith of any other change in name of business, change in thename of the person who holds the licence, a change of address or any other thing affecting the licence if granted. I further undertake to fulfill all duties and obligations ofa customs broker in accordance with the customs laws and regulations established there under. I understand that any false information or statement made hereinshall result in the immediate rejection of this application or revocation of any licence granted.

Signature: __________________________________________
30.

Date:

( FOR OFFICIAL USE ONLY)NAME OF BOARD MEMBER

RECOMMENDATION

SIGNATURE AND DATE SIGNEDSUBMITTED TO THE COMMISSIONER BY: …………….……………………………………………………DATE SUBMITTED: ……...…………….…

COMMISSIONER'S RULING ON THE APPLICATION: ………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………….

COMMISSIONER'S SIGNATURE: ……….……………………………………………………………………. DATE: ………………………………………

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