Form BXA0647P Delivery Verification Certificate

Form Approved: OMB No. 0694-0016, 0694-0093

FORM BIS-647-P
(REV.4/03)

U.S. DEPARTMENT OF COMMERCE
Bureau of Industry and Security

DELIVERY VERIFICATION CERTIFICATE
Public reporting burden for this collection of information is estimated to average 15 minutes per response,, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Director of Administration, room-3889, Bureau of
Industry and Security, U.S. Department of Commerce, Washington, D.C. 20230; and to the Office of Management and Budget Paperwork Reduction Project (06940016, 0694-0093) Washington, DC 20503.
Notwithstanding any other provision of law, no person is required to respond to nor shall a person be subject to a penalty for failure to comply with a collection of
information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number.
Instructions- When required to obtain a delivery verification, the U.S. Importer shall submit this form in duplicate, to the Customs Office. U.S. importer is required to
complete all items on this form except the portion to be completed by the U.S. Customs Service. The Customs Office will certify a Delivery Verification Certificate
only after the import has been delivered to the U.S. importer. The duly certified form shall then be dispatched by the U.S. importer to the foreign exporter or otherwise
disposed of in accordance with instructions of the exporting country.
No delivery verification may be obtained unless a completed application form has been received. (50 U.S.C App § 2401 et seq.,15 C.F.R. §748)
EXPORTER (Name and Address)

This certification applied to the goods described below, shown on

__________________________________________________

U.S. Department of Commerce International Import Certificate

Name
___________________________________________________________________________
Address
____________________________________
____________________ ____________
City
State/Country
Zip/ Postal Code

No.___________________________________________________

IMPORTER (Name and Address)

__________________________________________________

ARRIVED (Name of Port)

DATE OF ARRIVAL (mm/dd/yyyy)

NAME OF SHIP, AIRCRAFT, OR CARRIER (Include numbers
on bills of lading, airways bills, etc.)

Name
___________________________________________________________________________
Address
____________________________________
____________________ ____________
City
State/Country
Zip/ Postal Code
DESCRIPTION OF GOODS

TO BE COMPLETED BY U.S. CUSTOMS SERVICE
(Custom’s Seal)

ENTRY

□

QUANTITY

VALUE (FOB, CIR, etc)

REGION NO.

CERTIFICATION-It is hereby certified that the importer has produced evidence that the goods specified above have been delivered
and brought under the Export Administration Regulations of the United States.

______________________________________________________________
Signature
NUMBER
WAREHOUSE
CONSUMPTION

□

_________________________________________
Date
DATE