BUREAU OF CUSTOMS 
Customs Form 4455 
TREASURY DEPARTMENT 
10.8, 10.68, C. M. ; 
10.8, 10.28, 10.42, 10.68, C. R. 
April 1954 
APPLICATION FOR AND CERTIFICATE OF REGISTRATION OF ARTICLES TO BE EXPORTED FOR REPAIRS OR ALTERATIONS, 
PERSONAL USE, TOURING, ETC., ALSO THEATRICAL EFFECTS, MOVING-PICTURE FILMS, AND TRAVELERS’ SAMPLES 
Port of 
_ ( . Dec embe r 2? , S? 
To the Collector of Customs or Appraiser of Merchandise: 
Application is hereby made for inspection and certificate of registration of the follow¬ 
ing articles to be taken out of the United States, viz: 
Leica 3 camera •„ 70;fi37 with Sr..r>.i.cron lens 
(This space for use of examiner. If expor¬ 
tation is for repairs or alterations, notation 
should be made by examiner on both copies 
as to whether the work to be done is believed 
to be within the purview of Sec. 10.8, C. R.) 
(Describe fully, giving quantity, material, color, type, make, identification numbers, etc. One 
Leica lens liood 
unmounted photograph may be required) 
(Use reverse side for remainder of description of articles to be registered) 
Owner _ Obtained from_IftKB&flBUL CkM^MNl_ Place -IfaRl 
(Dealer) (Address) 
To be sent or taken abroad for the purpose of * ialri ”ff QmnfftmfMs, Ihprinf 
(Repairs, alterations, personal use, touring, etc.) 
(If for repairs or alterations, state nature thereof) 
January.! 
on or about 
To be shipped as_UcLgg&gQ- 
(Freight, baggage, etc.) 
(Carrier or mail) 
I declare that the above statements are correct and true 
Place___ Time___—__ 
(Articles must be delivered to appraiser for inspection. If such delivery is imprac¬ 
ticable for any reason, state on line above the place and time when inspection 
is desired) 
Address 
To the Examiner: You will examine the above-des<^ibe4 articles and make you/report hereon. 
To the Inspector: You will supervise the packing*, transfer, and lading of th^Xbove-described articles, and make your report 
hereon unless °tkerwis^3ir^t|^^ 
-d~4-Acting Deputy Collector or Appraiser . 
Port of 
I certify that I have examined the above-described articles and find the articles ip all particulars to be as set 
-V J / 
unless otherwise noted. “ fj 
Acting Ueputy Collector or Appraiser 
Examiner , 
INSPECTOR’S REPORT 
To the Collector: 
I certify that I have supervised the packing and transfer of the above-described goods and found them 
described above 
except as noted, and supervised the lading thereof on board the _ 
(Carrier or P. O. Register No.) 
on 
19 
Station_,_, 19—------ Inspector . 
This form to be filed in duplicate, one copy to be retained as customs record, and duplicate, when signed by appraiser or collector, to be delivered to 
applicant as a certificate for presentation to customs officers when articles are returned. If returned through another port, original must be transmitted 
to collector at port of entry on request. No fee. 
U. S. GOVERNMENT PRINTING OFFICE 16—9627-4 
