Please list total number of pages being transmitted:

  1. Submitter: Shipper, Importer, Consignee: 
  2. Submitter: Last Name, First Name: 
  3. Submitter:Firm Name, address, Fax,
  4. Transmitter/Broker:Contact Name and Address: TO BE PROVIDED BY DERINGER
  5. Firm Name and Address: TO BE PROVIDED BY DERINGER
  6. Shipper Registration Number: 
  7. Shipper Name and Address:
  8. Owner: 
  9. FDA Country Shipped From: 
  10. U.S. Customs Entry Number:TO BE PROVIDED BY DERINGER
  11. Entry type:Formal,TIB,Other: 
  12. Port of Arrival: 
  13. Anticipated date of arrival: 
  14. Anticipated Time of arrival – 24 hour clock: 
  15. Importer of Record: 
  16. Ultimate Consignee: 
  17. Mode of Transport: Truck, rail, air, ocean, private vehicle: 
  18. Carrier and Country: 
  19. Bill of Lading No., including SCAC code, or PAPS Code: 
  20. Vessel/Voyage No., Flight No., Trip No. : 
  21. Container Number, Car Number: 
  22. FDA Line Number: 
  23. Manufacturer Registration number if different than shipper: 
  24. Manufacturer Name and Address if different than shipper:
  25. FDA Product Code: 
  26. Common, usual, or market name: 
  27. Brand Name: 
  28. Quantity (Estimated is allowed): 
  29. Unit of measure: 
  30. FDA Value by FDA Line: 
  31. Lot/Code #: 
  32. Grower, if known: 
  33. Country of Production: 
  34. HTS Code: