Form Approved OMB No.

1651-0004
DEPARTMENT OF HOMELAND SECURITY Exp. 12-31-2010
U.S. Customs and Border Protection
APPLICATION FOR EXPORTATION OF ARTICLES UNDER SPECIAL BOND
19 CFR 10.38
TO CBP PORT DIRECTOR
1. TO: CBP Port Director (Address) 2. FROM: (Name and Address of Importer or Agent)

ATTACH COPY OF EXPORT INVOICE DESCRIBING ARTICLES TO BE EXPORTED

3. Name of Exporting Carrier 4. Date of Departure 5. Country of Origin 6. No. of Export Packages

7. Port of Entry 8. Entry Number Date 9. Date Bonded Period Expires

10. Date Articles Available for CBP Examination 11. Signature of Importer or Agent 12. Date

(FOR CBP USE ONLY)

NOTICE TO IMPORTER TO DELIVER ARTICLES TO BE EXAMINED AND IDENTIFIED FOR EXPORTATION
13. Place of CBP Examination Date

14. Date 15. CBP PORT DIRECTOR

BY:

REPORT OF EXAMINATION
16. The articles covered by this application have been examined and agree with the invoice in content and No. of export pkgs. and are approved for export.
17. No. of Export Packages 18. Date of Delivery for Exportation 19. Marks and Numbers on Export Packages

20. The articles covered by this application do not agree with the invoice in content or in number of packages as follows

21. SIGNATURE OF EXAMINING CBP OFFICER 22. DATE

REPORT OF EXPORTATION
23. Home of Exporting Conveyance (Vessel, Railroad, Airline and Flight Number)

24. Date of Departure Paperwork Reduction Act Statement: 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
25. Manifest No.
1651-0004. The estimated average time to complete this application is 8 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.

26. SIGNATURE OF CBP OFFICER

(CBP officer must return one copy of this (Previous Editions are Obsolete) CBP Form 3495 (06/09)
form to port of origin upon exportation.)