C-TPAT: Port Agent/Representative Information
  Please verify all information before submitting to Scan Security - thanks!
 

 

     
  Name of issuing Company
Name of Port Representative:
Company Name:
Facility Address: Line 1
  Facility Address: Line 2
City:
  State:
Postal Code:
  Province/Territory:
Country:
Phone No.:
Fax No.:   
e-Mail address:
    AUTHORIZATION
Please sign with the email address
of the Submitter of this information:
 

 

   
   

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