Form Approved OMB No. 1651-0005 Exp. 01-31-2010
DEPARTMENT OF HOMELAND SECURITY
CBP USE ONLY
U.S. Customs and Border Protection APPLICATION-PERMIT-SPECIAL LICENSE UNLADING-LADING-OVERTIME SERVICES
19 CFR 4.10, 4.30, 4.37, 4.39, 4.91, 10.60, 24.16, 122.29, 122.38, 123.8, 146.32, 146.34 1. Name of Vessel, Vehicle or Aircraft 3. Flag 2. Port 4. Name and Nationality of Owner/Operator No. Date/Time
Signature of CBP Officer
5. Name/Phone No. of Agent
6. Arriving from (Port Name and Country)
7. Date/Time of Arrival
8. Locations (Dock/Terminal)* Day Phone Night Phone
9. Application is made for a permit for the operations indicated: (1) To unlade merchandise (intended to be unladen at this port, as shown by the manifest), baggage or passengers. To discharge ballast, and to land ''in bond'' merchandise. (Sec. 551, Tariff Act of 1930). (2) To land supplies, ship's stores, sea stores, or equipment not to be reladen, subject, however, to free or duty-paid entry (Sec. 446, Tariff Act of 1930). (3) To lade merchandise or baggage requiring CBP supervision. (4) To land and release for repair, adjustment, or refilling and to relade under CBP supervision articles of carrier's equipment. (Articles to be listed reverse side hereof showing date and hour of unlading and relading.) The undersigned certifies the articles listed on the reverse hereof for release under this term is to be landed only for the purpose mentioned in this item and will be reladen on this carrier. (5) Other 10. Itinerary of Vessel/Aircraft (show port country and departure dates for entire voyage including U.S. itinerary)*
11. TYPE OF CARGO:
12. List all carriers, including carriers sharing or chartering space onboard the vessel and check the box that describes how the carrier presented the cargo manifest.*
13. Application is made for a special license for overtime services of CBP officers and employees for: Entrance, Clearance on
Unlading, lading, etc. at
Other: Per supplemental oral request
14. Bond No. 16. Principal on Bond 20. Importer Number (Party to be billed; show hyphens)
15. Application is made for a Term Permit and Special License From: 17. Surety Company Code 21. Address of Agent 22. Signature 23. Date To: 18. Amount of Bond 19. Date of Bond
This PERMIT is not valid until properly lodged with a CBP officer at the point of discharge and all operations indicated therein are performed under CBP supervision.
*use back for additional space; (Instructions and Paperwork Reduction Act Notice on reverse)
CBP Form 3171 (01/02)
CONTINUED FROM ITEM #9 (4): RECORD OF ARTICLES RELEASED AND RELADEN UNLADEN AND RELEASED RELADEN
Date Time Description of Articles Signature Released to Company Insp. Badge # Date Time Insp. Badge #
Continued from # 8 - additional Locations:
Continued from # 9 (5) - Other:
Continued from # 10 - additional Itinerary of Vessel:
Continued from # 12 - additional SCAC Codes:
INSTRUCTIONS CBP Form 3171 shall be filed in duplicate. (When a term permit is requested, additional copies may be required for local purposes). Items shall be completed as follows: 1. 2. 3. 4. 5. 6. 7. 8. 9. Name or number of vessel, vehicle, or aircraft (On term permit ''Not Applicable.'') Port at which application is filed. Flag of vessel. Name of shipping company, airlines etc., which owns or operates the vessel, vehicle or aircraft and their nationality. Name and day/night phone numbers of party filing application. Name of port or place and country from which a vessel, vehicle, or aircraft is arriving. (On Term Permit show ''Not applicable.'') Give the date of arrival or expected arrival when request covers a specific vessel, vehicle, or aircraft. List all places of lading, unlading, etc. If request is for overtime services only state where services are to be performed. Check appropriate items. 14. 15. 13. 10. 11. 12. Show port, country and sailing dates for the itinerary of the vessel/aircraft, including U.S. itinerary. Check the appropriate box/boxes. List all carriers, including carriers sharing or chartering space onboard the vessel and check the box that describes how the carrier presented the cargo manifest. Indicate purpose for which services are requested and date and time. (If date and time are not known, check "per supplemental oral request.") Self-Explanatory. When requesting a term permit, show dates or period to be covered.
16-21. Self-Explanatory. 22-23. Signature and date of party submitting request.
PAPER REDUCTION ACT NOTICE: The Paperwork Reduction Act says we must tell you why we are collecting this information, how we will use it, and whether you have to give it to us. We ask for the information to carry out the Customs Service laws of the United States. This form is used by carriers to request specific CBP services relating to the lading or unlading of merchandise and by CBP to authorize requested activities. It is also used to permit and control various statutes. Another major use of this form is to request CBP services during other than regular hours of service. It is mandatory. Statement Required by 5 CFR 1320.21: The estimated average burden associated with this collection of information is 8 minutes per respondent or recordkeeper depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to U.S. Customs and Border Protection, Information Services Branch, Washington, DC 20229, and to the Office of Management and Budget, Paperwork Reduction Project (1651-0005), Washington, DC 20503.
CBP Form 3171 (Back)(01/02)