REPRODUCE LOCALLY.  Include form number and edition date on all reproductions.                                                                           0MB APPROVED NO. 0581-0123

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.

FV-356 (7-04) Previous editions are to be destroyed                                                                                                                                                        (OVER)

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

FV-356 (07-04) (REVERSE)