Application for Brokerage Account

Important Notes - please read before completing this form: Online submission of this form will enable The Canadian Customs House Limited to set up your new Brokerage Account. However, you must print this form, provide the required notarisation and signatures, then mail or FAX the completed form to us at PO Box 220 Lakefield Ontario K0L 2H0 FAX 1 705-651-5757 or scan and email to info@canadiancustomshouse.ca before any business can be transacted. All Required Fields (with an asterisk *) must be completed before this form can be submitted

Contact Information

Name (Company or Individual)*

Street address*

City*

Province/State*

Postal/ZIP code*

Country

Email Address*

Telephone*

Ext:

FAX (optional)

Applicant Details

Applicant Status*

CorporationIndividual/Sole Trader/Partnership

GST Registered?*

YesNo

GST Number*

Business Number (if applicable)

General Agency Agreement Appointing The Canadian Customs House Limited - including Power of Attorney with Power to Appoint a Sub-Agent

We (Name of company per Corporate Registration)*

I/We (Name(s) of Individual or partners )*

do hereby constitute and appoint The Canadian Customs House Ltd., my/our true and lawful attorney to transact business on all matters relating to:1. Customs that may be transacted by a customs broker licensed under the Customs Act.2. Excise under the Excise Tax Act and any tax or levies under the Excise Tax Act.3. Matters relating to the accounting for payment and refund of Customs and/or excise duties,excise tax and goods and services tax in respect to imported goods released or to be released under such legislation, at the following customs office(s): ALL CUSTOMS OFFICES IN CANADA4. Arranging all Exports from Canada with respect to C.B.P. or United States Customs Service and in connection therewith:(a) to execute, sign, seal, deliver and endorse all bonds, entries, bills of lading, bills of exchange, warehouse receipts or other means of payments or collateral security which comes into his possession and to use same, including drawbacks and claims of any nature for reimbursement of customs duties, sales and excise taxes and the like;(b) to receive all such payments and sums of money as are now due or may hereafter become due and payable to me by way of rebate, refund or remission on the order of the Department of National Revenue (Customs & Excise) relative to the foregoing; and to endorse on my behalf and as my attorney and to deposit to and for his own account all such payments from the Government of Canada.I acknowledge that any duties, charges or other amounts paid on my behalf or to my account by my attorney or sub-agent shall be debt due by me or my attorney or sub-agent and any refund, rebate or remission of such duties, charge or other amounts shall be the property of my attorney or sub-agent and I direct and authorize any Governmental Agencies collecting same to deliver such refunds, rebates or remissions to my attorney.

We (Name of company per Corporate Registration)*

I/We (Name(s) of Individual or Partners*

hereby certify that, to the best of my knowledge, all documents and/or information that will be provided to my aforesaid attorney by myself or on my behalf. In connection with this mandate, will be true, accurate and complete. I further grant my attorney full power and authority to appoint any other person to whom a license to transact business as a Customs Broker has been issued under the Customs Act as a sub-agent to transact the aforesaid business on my behalf at any of the aforementioned Customs offices, and to revoke any appointment and to appoint any other person who holds such a license as a sub-agent in the place of any sub-agent whose appointment has been revoked, as he, my attorney, shall from time to time think fit.

I/We hereby ratify and confirm and agree to ratify and confirm all that my said attorney may do by virtue hereof;The Power of Attorney shall be and remain in full force and effect, until due notice of revocation shall have been given to my aforesaid attorney, in writing by registered mail.

In Witness Whereof

We (Name of company per Corporate Registration)*

I/We (Name(s) of Individual or Partners )*

Attested to by the signature of its duly authorized Official(s) at:

Municipality

Province or State

Witness Signature

Applicant Signature

Name & Corporate Title

Corporate Seal (affix)

Name(s) of Individual or Partners*

Social Insurance Number(s)*

Date (DD/MM/YYY)

GST Agreement

This will confirm our arrangement with respect to the payment of the taxes levied under the Excise Tax Act (GST) on Imported goods, which you will clear through Canada Revenue Agency on our behalf using your release prior to payment privileges.We agree to provide you with separate payment by cheque for the full amount of the GST owing on these goods. The cheque will be made payable to the Receiver General for Canada and will be available for remittance to Canada Revenue Agency, through you, by the last business day of the month to which the billing period applies.This will acknowledge that under this arrangement, failure to provide such payment by the due date will result in the assessment of interest on the outstanding amount. We accept full responsibility and liability for the payment of interest assessed in this way.We further acknowledge that non-payment of any and all amounts may result in the loss of this option for the release of future importations on our behalf, whether prior to payment of duties and taxes or otherwise, until all debts including interest charges have been paid in full to Canada Revenue Agency.

In the event that payment is not provided within the required time limits, Canada Revenue Agency may contact:

Telephone:

FAX:

Contact Name:*

Title:*

Signature:

Date:

Date

GST Account Number (if applicable)

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