U .S . DE PA R T M E N T OF COM M E R CE — U .S . CE N S U S B U R E A U – E conom ics and S tatis tics A dm inis tration — B U R E A U OF E X POR T A DM IN IS T R A T ION
FOR M
7 5 2 5 -V
S H IP P E R ’ S E X P O R T D E C L A R A T IO N
(7-25-2000)
OM B N o. 0607-0152
1 a . U .S . PR IN CIPAL PAR TY IN IN TE R E S T (U S PPI) (Complete name and address)
ZIP CODE
b. U S PPI E IN (IR S ) OR ID N O.
2 . DATE OF E X POR TATION
3 . TR AN S POR TATION R E FE R E N CE N O.
6 . POIN T (S TATE ) OF OR IG IN OR FTZ N O.
7 . COU N TR Y OF U LTIM ATE DE S TIN ATION
c . PAR TIE S TO TR AN S ACTION
R elated
Non-related
4 a . U LTIM ATE CON S IG N E E (Complete name and address)
b. IN TE R M E DIATE CON S IG N E E (Complete name and address)
5 . FOR W AR DIN G AG E N T (Complete name and address)
8 . LOADIN G PIE R (Vessel only)
9 . M ETHOD OF TR ANS POR TATION (S pecify) 1 4 . CAR R IE R IDE N TIFICATION CODE
1 1 . POR T OF E X POR T
1 0 . E X POR TIN G CAR R IE R
1 5 . S HIPM E N T R E FE R E N CE N O.
1 6 . E N TR Y N U M B E R
1 7 . HAZAR DOU S M ATE R IALS
1 8 . IN B ON D CODE
1 9 . R OU TE D E X POR T TR AN S ACTION
Y es
1 2 . POR T OF U NLOADING (Vessel and air only) 1 3 . CON TAIN E R IZE D (Vessel only)
Y es
No
Y es
2 0 . S CHE DU LE B DE S CR IPTION OF COM M ODITIE S (U se columns 22–24)
D/F
or M
(21)
No
S CHEDU LE B NU M B ER
QU ANTITY –
S CHEDU LE B U NIT(S )
S HIPPING W EIG HT
(Kilograms)
(22)
(23)
(24)
No
VIN/PR ODU CT NU M BER /
VEHICLE TITLE NU M BER
VALU E (U .S . dollars,
omit cents)
(S elling price or cost if not
sold)
(25)
(26)
S A M P L E
2 7 . LICE N S E N O./LICE N S E E X CE PTION S Y M B OL/AU THOR IZATION
2 9 . Duly authorized officer or employee
2 8 . E CCN (W hen required)
T he U S PPI authorizes the forwarder nam ed above
to act as forwarding agent for export control and
cus tom s purpos es .
3 0 . I certify that all s tatem ents m ade and all inform ation contained herein are true and correct and that I have
read and unders tand the ins tructions for preparation of this docum ent, s et forth in the " C o r r e c t W a y t o
F ill O u t t h e S h ippe r ’ s E x po r t D e c la r a t ioInunders
."
tand that civil and crim inal penalties , including
forfeiture and s ale, m ay be im pos ed for m aking fals e or fraudulent s tatem ents herein, failing to provide
the reques ted inform ation or for violation of U .S . laws on exportation (13 U .S .C. S ec. 305; 22 U .S .C. S ec.
401; 18 U .S .C. S ec. 1001; 50 U .S .C. A pp. 2410).
S ignature
C o n f iden t ia l –For use solely for official purposes authorized by the
S ecretary of Commerce (13 U .S .C. 301 (g)).
Title
E xport shipments are subject to inspection by U .S . Customs S ervice
and/or Office of E xport E nforcement.
Date
3 1 . AU THE N TICATION (W hen required)
Telephone N o. (Include Area Code)
E -mail address
This form may be printed by private parties provided it conforms to the official form. For sale by the S uperintendent of Documents,
G overnment Printing Office, W ashington, DC 20402, and local Customs District Directors. The " C o r r ec t W a y to F ill O ut the S hipper ’ s
E x po r t D ec la r a tio n" is available from the U .S . Census B ureau, W ashington, DC 20233.