U.S. PRINCIPAL PARTY (USPPI) AND ADDRESS*

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FIRST AND LAST NAME*

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PHONE NUMBER*

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USPPI EIN (IRS) or ID Number*

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RELATED PARTIES TO TRANSACTION

NON RELATED PARTIES TO TRANSACTION

RELATED PARTIES TO TRANSACTION UNKNOWN

TRANSPORTATION REFERENCE NO.*

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DATE OF EXPORTATION*

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INTERMEDIARY CONSIGNEE NAME, ADDRESS

ULTIMATE CONSIGNEE NAME, ADDRESS *

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ULTIMATE CONSIGNEE TYPE (DIRECT CONSUMER)

ULTIMATE CONSIGNEE (GOVERMENT ENTITY)

ULTIMATE CONSIGNEE (RESELLER)

ULTIMATE CONSIGNEE (OTHER)

EQUIPMENT NUMBER(S)

SEAL NUMBER(S)

AUTHORIZED AGENT NAME AND ADDRESS*

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STATE OF ORIGIN/FTZ NO.*

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COUNTRY OF ULTIMATE DESTINATION*

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METHOD OF TRANSPORTATION*

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EXPORTING CARRIER/CONVEYANCE NAME*

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PORT OF EXPORT*

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PORT OF UNLADING*

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CONTAINERIZED

NON CONTAINERIZED

CARRIER SCACCODE

SHIPMENT REFERENCE NO.*

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ENTRY NUMBER

HAZARDOUS MATERIALS

NO HAZARDOUS MATERIALS

IN BOND CODE

ORIGINAL ITN

ROUTED EXPORT TRANSACTION

NON ROUTED EXPORT TRANSACTION

DESCRIPTION of COMMODITIES*

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SCHEDULE B/HTS NUMBER

QUANTITY - UNIT(S)*

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SHIPPING WEIGHT (KG)*

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NET WEIGHT (KG)

VIN/PRODUCT NUMBER/VEHICLE TITLE NUMBER

VALUE (U.S)*

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APPLICANT'S EMAIL *

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*US Agent must be authorized by the FPPI for purposes of preparing and filing the Electronic Export Information (EEI). I certify that the statements made and all information contained here in are true and correct. I understand that civil and criminal penalties,including forfeiture and sale, may be imposed for making false and fraudulent statements herein., failing to provide the requested informationor for violation of U.S. laws on exportation (13 U.S.C. Sec. 305: 22 U.S.C. Sec. 401, 18 U.S.C. Sec. 1001, 50 U.S.C. app. 2410).*

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* Indicates required fields

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