Name *

First Name

Last Name

Street Address (Canada) *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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I authorize and appoint Bluebird Customs, LLC to be my lawful attorney-in-fact to act on my behalf as authorized agent of the Principal Party of Interest (PPI) for, and in the name, place, and stead of the PPI, to act as authorized agent for export control, U.S. Census Bureau reporting, and U.S. Customs and Border Protection purposes, and to transmit export information electronically on behalf of the PPI for one vehicle export only. The PPI certifies that all documentation is valid and assumes responsibility for accuracy. The PPI further understands that civil and criminal penalties may be imposed for making false or fraudulent statements or for the violation of any U.S. laws or regulations on exportation. PPI is further responsible for paying all taxes and fees related to export. *

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