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DATE:
Company:
Name/Dept: Street/State/Zip: Telephone:
TO:
Name/Dept:
Street/State/Zip: Telephone:
DESCRIPTION:
QUANTITY:
WEIGHT: (Mail Services Only)
CONTENTS:
NOT FOR RESALE THE ABOVE CONTENTS HAVE NO COMMERCIAL VALUE FOR CUSTOMS PROPOSED VALUE SET AT $ U.S. DOLLARS
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE
SIGNATURE YOUR NAME TITLE, DEPARTMENT