Lacey Act Declaration Form

SECTION 1 - Shipment Information
1 . ESTIMATED DATE OF ARRIVAL : (MM,DD,YYYY)
JAN 16, 2016 to MOUNT AIRY - NC. - U.S.A.
2 . ENTRY NUMBER : 3 . CONTAINER NUMBER :
TCNU8933013 - ZGLD411598
4 . BILL OF LADING : 5 . MID :
6 . IMPORTER NAME : 8 . CONSIGNEE NAME :
PT. HADINATA BROTHERS LIGNA USA INC
7 . IMPORTER ADDRESS : 9 . CONSIGNEE ADDRESS :
JL. TAPOS KM.1, CIBINONG 16901 159 MOUNTVIEW DR
INDONESIA MOUNT AIRY NC 27030
U.S.A.
I certify under penalty of perjury that, to the best of my knowledge and belief, the information furnished in true and correct:
6-Dec
Knowing making a false statement in this Declaration for Importation may subject the declarant to criminal penalties in accordance with 16 U.S.C. 3373(d).
PPQ FORM 505
APRIL 2009
Santy Herdiana
Signature
Date
Type or Print Name