U.S. DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

APPLICATION FOR INSPECTION AND CERTIFICATE OF SAMPLING

APPLICATION

TAKEN BY (Initials)

DATE

HOUR

NAME AND MAILING ADDRESS OF APPLICANT (Include City, State, ZIP)

Enter your E-Mail Address here:     

NAME AND MAILING ADDRESS OF RECEIVER OR BUYER (Include City, State, ZIP)

IF REQUEST BY OTHER THAN APPLICANT, SPECIFY NAME OF PARTY

CONTRACT OR ORDER NUMBER

DATE AVAILABLE FOR SAMPLING/INSP.

NOTE:  Mark an �X� in appropriate blocks

MAIL CERTIFICATE AND FEE BILL TO

 APPLICANT                 OTHER (Specify)

TYPE OF PRODUCT     CANNED    FROZEN    DRIED    DEHYDRATED    OTHER

NAME OF PRODUCT     

 LOCATION OF PRODUCT

Contact Person:                                         

Phone No.:                                             

TYPE OF CASE

  NONE       DOMESTIC         OTHER (Specify)

CASE MARKS (Specify in �Remarks� on reverse)

  COMMERCIAL                      SPECIAL

PRODUCT PREVIOUSLY GRADED

  NO                                         YES (If �Yes�, give Certificate Number)

FIELD OFFICE WHERE GRADED

REPORT RESULTS IMMEDIATELY AFTER GRADING TO

 APPLICANT                           OTHER (Specify)

QUALITY REQUIREMENTS OF RECEIVER

ADDITIONAL REQUIREMENTS

 Certificate of Date of Pack (Federal or State Agencies).

 Condition of Container Examination (Federal or State Agencies).  Attach Form AD-748 or 741 when accomplished.

  �Officially Sampled� stamp on cases.  Stamp this form when accomplished.

 USDA Contracts � Country of Origin Certification and Traceability Documents.

 Checkloading  Required  Date: 

LOT NO.

LOT SIZE AND

DESCRIPTION

NO. AND TYPE OF

CONTAINERS IN CASE

CODE MARKS IN LOT

 EMBOSSED      INK STAMPED     INK JET     OTHER

NO.  SAMPLES

ADDITIONAL SAMPLE UNITS FOR:       ANALYTICAL      USDA REVIEW      MONTHLY REVIEW      OTHER                    

REMARKS:     

THIS IS TO CERTIFY that in compliance with the regulations of the Secretary of Agriculture governing the inspection of processed fruits and vegetables pursuant to the Agricultural Marketing Act of 1946, as amended, I have this day drawn samples believed by me to be representative of the lots described above.

    DATE           ADDRESS OF SAMPLER OR FIELD OFFICE                                                   OFFICIAL SAMPLER PRINT AND SIGN NAME

DATE

DRIVING

(HRS)

SAMPLING

(HRS)

STAMPING

(HRS)

CONDITION

(HRS)

CHECKLOADING

(HRS)

PRODUCT

EXAM (HRS)

OTHER (HRS)

TOTAL

HOURS

OVERTIME

(HRS)

NIGHT              DIFF (HRS)

INSPINT.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number.� The valid OMB control number for this information collection is 0581-0123.� The time required to complete this information collection is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual�s income is derived from any public assistance program (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA�s TARGET Center at (202) 720-2600 (voice and TDD).� To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

CERTIFICATE OF SAMPLING

THIS IS TO CERTIFY that in compliance with the regulations of the Secretary of Agriculture governing the inspection of processed fruits and vegetables pursuant to the Agricultural Marketing Act of 1946, as amended, I have this day drawn samples believed by me to be representative of the lots described below.

CONTRACT NUMBER

PURCHASE ORDER NUMBER

NAME AND MAILING ADDRESS OF APPLICANT (Include City, State, Zip)

NAME AND LOCATION OF WAREHOUSE (Include City and State)

PRODUCT

SIZE AND KIND OF CONTAINERS

TYPE OF CASE (if cased)   CORRUGATED    HALF CASE    OTHER                  

NUMBER PER CASE

CASE MARKINGS (if any)

LOT NO.

NO. SAMPLES

CODE MARKS

~ EMBOSSED    ~ INK STAMPED  ~  INK JET  ~  OTHER                 

NO. CASES

LOCATION IN WAREHOUSE

REMARKS

DATE

OFFICIAL SAMPLER PRINT AND SIGN NAME

ADDRESS OF FIELD OFFICE/INSPECTION POINT