Samples Carried in Transit Through Canada in Private Vehicle
_______________________________
(U.S. port of exit printed here) (Date)
I have checked the quantity and values of the below-listed articles carried by ____________________(Name and address of traveler) and owned by ____________________(Name and address of firm or company)
These articles are contained in ________ (Number) packages which have been corded and sealed for in-transit movement through Canada to ________ (U.S. port of reentry) in ________ (Year, make and license number of vehicle)
(U.S. Customs Inspector)
Description of merchandise Value
_______________________________
_______________________________
_______________________________
When the traveler arrives at Customs with lists already prepared, the form may be inscribed "as per list attached."
19 C.F.R. §123.51