Form 4455 Certificate of Registration

OMB Control Number: 1651-0010
Expiration Date: 02/29/2016

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection

NO.

CERTIFICATE OF REGISTRATION
19 CFR 10.8, 10.9, 10.68,
148.1, 148.8, 148.32, 148.37

(NOTE: Number of copies to be submitted varies with type of transaction.
Inquire at Port Director's office as to number of copies required.)
B/L or INSURED NO.

VIA (Carrier)
NAME, ADDRESS, AND ZIP CODE TO WHICH CERTIFIED FORM IS
TO BE MAILED (If Applicable)

Number
Packages

Kind of
Packages

DATE
ARTICLES EXPORTED FOR:

ALTERATION*
REPAIR*
USE ABROAD
REPLACEMENT

PROCESSING*
OTHER, (specify)

* NOTE: The cost or value of alterations, repairs, or processing abroad
is subject to CBP duty.
LIST ARTICLES EXPORTED
Description

DATE

SIGNATURE OF OWNER OR AGENT (Print or Type and Sign)
The Above-Described Articles Were:
DATE

EXAMINED
PORT

SIGNATURE OF CBP OFFICER

DATE

LADEN under my supervision
PORT

SIGNATURE OF CBP OFFICER

CERTIFICATE ON RETURN
Duty-free entry is claimed for the described articles as having been exported without benefit of drawback and are returned unchanged except as noted: (use
reverse if needed)

SIGNATURE OF IMPORTER (Print or Type and Sign)

DATE

NOTE: Certifying officers shall draw lines through all unused spaces with ink or indelible pencil.
Paperwork Reduction Act Notice: An agency may not conduct or sponsor an information collection and a person is not required to respond to this
information unless it displays a current valid OMB control number and an expiration date. The control number for this collection is 1651-0010. The estimated
average time to complete this application is 10 minutes. If you have any comments regarding the burden estimate you can write to U.S. Customs and
Border Protection, Office of Regulations and Rulings, 799 9th Street, NW., Washington DC 20229.

CBP Form 4455 (06/12)