Revised 10-15-2018

Owner of household Goods

Last Name:

First Name:

Middle:

Date of Birth:

Passport No:

Citizenship:

Resident Alien No:

U.S. Address:

City:

Foreign Address:

City:

State:

Zip Code:

State:

Zip Code:

Country

Phone Number:

Country

Phone Number:

Employment Information

Employer:

Length of Employment:

Position with the Company:

Nature of Business:

Reason for Moving:

Name and telephone of company official who can verify the above information:

Name of Freight Forwarders

Name of Packers

Address:

City

State

Zip Code

City

State

Zip Code

Country

Name of Shipping Agent Address

City

State s

Zip Code

Country

Shipment Itinerary (Specify place of loading and intermediate ports) Certification: (Check one)

4500 NW 36 Street, Miami, FL 33166, www.amerijet.com