Return Completed Application to Avalon S San Francisco Office No Later Than 11:00 A

Avalon Risk Management

Carnet Application

Please return completed application to Avalon’s San Francisco office () no later than 11:00 a.m. Pacific time.

A. Holder Information

1. Carnet Holder (Corporation or Individual):

Contact Name:

Street Address:

City: State: ZIP:

Phone No.: Fax No.: Email:

2. IRS/SS No.: 3. Parent Company: IRS # of Parent Company:

4. Person Duly Authorized and Title:

5. Authorized Representatives who will be shipping or hand carrying the merchandise on the Carnet:

Billing Reference Number:

B. Carnet Preparation/Country Information

6. Goods to be exported as:
(mark more than one if applicable) / Professional Equipment (PE)
Commercial Samples (CS)
Exhibitions and Fairs (EF) / 7. Approximate Date of Departure from the U.S.:
(enter date as “MM/DD/YY”)
8. Type the NUMBER of visits in the space provided beside each country you expect to visit:
Albania (AL)
Algeria (DZ)
Andorra (AD)
Antarctica (AQ)
Aruba (AW)
Australia (AU)
Austria (AT)
Bahrain (BH)
Balearic Islands
Belgium (BE)
Belarus (BY)
Bosnia and Herzegovina (BA)
Botswana (BW)
Bulgaria (BE)
Canada (CA)1
Canary Islands (IC)
Ceuta (ES-CE)
Chile (CL)
China (CN)2 – Call First
Corsica (FR-H)
Curacao
Croatia (HR)
Cyprus (CY)
Czech Republic (CZ)
Denmark (DK)
Estonia (EE)
European Union (EU) / Finland (FI)
France (FR)
French Guiana (GF)
Germany (DE)
Gibraltar (GI)
Greece (GR)
Guadeloupe (GT)
Guernsey (CG)
Guam (GU)
Hong Kong (HK)
Hungary (HU)
Iceland (IS)
India (IN)2
Indonesia (ID)
Iran (IR)
Ireland (IE)
Isle of Man (IM)
Israel (IL)
Italy (IT)
Ivory Coast (CI)
Japan (JP)
Jersey (JE)
Korea (KR)
Latvia (LV)
Lebanon (LB)
Lesotho (LS)
Liechtenstein (LI) / Lithuania (LT)
Luxembourg (LU)
Macao (MO)
Macedonia (MK)
Madagascar (MG)
Malaysia (MY)
Malta (MT)
Martinique (MQ)
Mauritius (MU)
Mayotte (YT)
Melilla (ES-ML)
Mexico (MEX)
Moldova (MD)
Monaco (MC)
Mongolia (MN)
Montenegro (ME)
Morocco (MA)2
Namibia (NA)
Netherlands (NL)
New Caledonia (NC)
New Zealand (NZ)
Norway (NO)
Pakistan (PK)
Poland (PL)
Portugal (PT)
Puerto Rico (PR)
Reunion Island (RE) / Romania (RO)
Russia (RU)
Senegal (SN)
Serbia (RS)
Singapore (SG)
Slovakia (SK)
Slovenia (SI)
South Africa (ZA)
Spain (ES)
Sri Lanka (LK)
St. Barthelemy
St. Martin, French side
St. Pierre
Swaziland (SZ)
Sweden (SE)
Switzerland (CH)
Tahita (PF)
Taiwan (TW) – Call First
Tasmania
Thailand (TH)
Tunisia (TN)3
Turkey (TR)
Ukraine (UA)
United Arab Emirates (UAE)
United Kingdom (GB)
Wallis & Futuna Islands
Other
1 certain PE items are admitted / 2only EF items for certain events / 3 CS items are not admitted
9. Number of times your merchandise will be leaving and re-entering the U.S.:
10. Number of countries transiting(s): List countries to be transited:
11. Type of Transit Ocean Air
12. Would you like a replacement carnet on this shipment? Yes No
13. What is the purpose of this trip?

C. Time

14. When do you need the original Carnet? 48 Hours (Standard Service) 24 Hours (Rush Service) Same-Day Processing

D. Send the original Carnet to:

15. Corporation or Individual:

Contact Name:

Street Address: City: State: ZIP:

Phone No.: Fax No.:

840 Hinckley Road | Suite 100 | Burlingame, CA 94010

Phone: (650) 652-4100 | Fax: (650) 898-1503 | www.avalonrisk.com

Form B112A REV 2016/01/05 CA License# 0G98514