Tel: +(501) 671-2601

Customs & Excise Headquarters

Caesar Ridge Rd, Belize City
cbccbelize@gmail.com

GST TIN:____________

APPLICATION FOR A CUSTOMS BROKER’S LICENCE

Complete all sections as fully as possible and attach supplementary sheets, where necessary.

Completed application form, and supporting documentation (Police record, Company registry
certificate), together with the bank deposit receipt of appropriate application fee ($50.00), should be
submitted in duplicate to the Secretary of the Board, Customs Brokers and Customs Clerks Board,
Customs House, Belize City, Belize. Bank Deposit must be made at Atlantic Bank A/c #
100305493 in the name of CUSTOMS BROKERS AND CUSTOMS CLERKS BOARD.

1. Name of applicant:

__________________________________________________________________________
(Given name) (Surname) (Any other names)

2. Registered Business Address:

_________________________________________________________________________

3. Contact details:

Tel:______________ Mobile #:______________ E-mail:_______________________

4. Date of birth: ____/_____/_________

dd / mm / year

5. Place of birth: ____________________________________________

(Attach a certified copy of the birth certificate or other form of identification)

6. Are you a resident of Belize or CARICOM?

( ) Yes ( ) No

If ‘No”, state your place of residence

________________________________________________________

7. School/College attended ____________________________________

Certificate/Degree awarded _________________________________
 Graduate studies ___________________________________________

Certificate/Degree awarded ___________________________________

Others ____________________________________________________

____________________________________________________

____________________________________________________
(Continue on a separate sheet, if necessary)

8. State present employment

DATE EMPLOYER AND ADDRESS POSITION HELD

__________________________________________________________

__________________________________________________________

9. I give permission to contact my present employer.

( ) Yes ( ) No

10. Have you been indicted of an offence involving dishonesty during the past five (5) years,
whether in Belize or elsewhere?

( ) Yes ( ) No

If “Yes”, give details.

________________________________________________________

________________________________________________________

Dated this _______ day of _____________ 20______

I hereby declare under penalty of perjury that I am acting on my own behalf, and that the
foregoing statements are true and correct to the best of my knowledge and belief.

_____________________
(Signature of Applicant)

Customs Brokers & Customs Clerks Board 4/2019

 I, _____________________________, of ______________________________________ and
(Name of Justice of Peace / Notary Public) (Home address)

currently employed as ________________________ hereby declare that I have been

(Profession)

acquainted with the applicant _____________________________ for the past

( Applicant’s full name)

__________ years through ________________________________ and that the

(number of years) (Relationship to Applicant)

information provided in this application is true and correct to the best of my knowledge,
information and belief.

Subscribed and sworn to before me this_______ day of _____________ 20______

SEAL _________________________________
Justice of the Peace or Notary Public

Customs Brokers & Customs Clerks Board 4/2019