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Customs Declaration Form (Pos 401D)

1. Name and address of sender
2. Sender's Customer reference (if any)
3. Name and address of addressee
4. Office of exchange
5. Customs stamp
6. Service required)
7. Customs duty
8. Declaration by addressee
9. Date and addressee's signature
10. Date and sender's signature
11. Item no.
12. Insured Value - Words, Figures
13. Cash-on-delivery amount - Words, Figures
14. Importer's reference (if any) (tax code/VAT No./importer code) (optional)
15. Importer's telephone/fax/e-mail (if known)
16. (Please affix official labels here, when required)
17. Office of origin/Date of posting
18. Number of item
19. Number of certificates and invoices
20. SDR Insured value SDR
21. Total gross weight
22. Charges
23. Sender's instruction in case of non-delivery.