Import Customs Declaration Form

Medical Equipment

Date:
Declaration No.:

Importer Information

Name of Importer:
Company Name:
Address:
Contact Number:
Email:

Consignee Information

Name:
Company/Institution:
Address:
Contact Number:
Email:

Shipment Details

Country of Export:
Port of Entry:
Method of Transportation:
Expected Arrival Date:
Invoice Number:
Invoice Date:

Medical Equipment Details

No.	Description of Equipment	Model/Serial No.	Quantity	Unit Value	Total Value
1
2
3

Additional Information

Purpose of Import:

Relevant Licenses/Permits (if any):

Declaration

I hereby declare that the information provided above is true and correct to the best of my knowledge and that all applicable import regulations have been complied with.

Name:
Position/Title:
Signature:
Date: