CUSTOMER INFORMATION SHEET
CUSTOMER NAME  :________________________  CUSTOMER NUMBER_________________________
DBA/AKA/DIV          :________________________________________  NEW_____ADD_____CHANGE______UPDATE________
STREET ADDRESS  :____________________________________ SALESPERSON NAME:________________________________
P. O. BOX/SUITE      :____________________________________SALESPERSON #          :_______________________________
CITY:_________________________STATE/PROVINCE____________________ ZIP/POSTAL CODE_______________________

CONTACT/TITLE__________________________________

TELEPHONE: (____)_____________________________________ FAX:( _____ )__________________________________________

MERCHANDISE DESCRIPTION:_____________________________________________________

CUSTOMS RULINGS YES(       )     NO(        )            RULING NUMBER(S)__________________________________________

TERMS OF SALE/DISCOUNTS__________________________________PORTS OF ENTRY______________________________

BOND INFORMATION:
BOND   YES(       )    NO(       )      IMPORTER  #_________________________________SURETY  #_______________________

EFFECTIVE DATE___________________   BOND AMOUNT $_______________________ APPROVAL  #___________________

DID YOU LEAVE:          P/A    YES(       )    NO(        )              BOND APPLICATION     YES(        )       NO(        )

FEES:
04)    ENTRY FEES:____________________________________ MIN:__________________________  MAX:___________________

04)    SURCHARGE:__________________________PER HUNDRED

05)    T B C S BOND CHARGES:_________________________PER THOUSAND MIN:_______________MAX:_______________

10)    S E B     BOND CHARGES:_________________________PER THOUSAND MIN:_______________MAX:_______________

06)    NAFTA________________    07)    ADD'L INV______________________    08)    ADD'L CLASS_______________________

11)    VISA FEE________________    48)    MPF_____________________     55)     FDA RELEASE _________________________

64)    ID RELEASE_________________  69)    CENSUS STAT_________________   83)    COTTON FEE ___________________

90)    BCS RELEASE___________________   FWRDING______________ MISC(                          )_________________________

REMARKS/ADD'LINFORMATION:_______________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
ADMINISTRATIVE APPROVAL:_________________________________   DATE______________________
ADDED TO SYSTEM                 :_________________________________   DATE______________________
CHAMP FORM 20 (REVISED 09/20/94)