FV-356 Application for Inspection and Certificate of Sampling

REPRODUCE LOCALLY. Include form number and edition date on all reproductions.
U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

OMB APPROVED NO. 0581-0234
FV356 (X-XX) Previous edition are to destroyed
DATE
HOUR

APPLICATION
TAKEN BY (Initials)

APPLICATION FOR INSPECTION AND CERTIFICATE OF
SAMPLING
NAME AND MAILING ADDRESS OF APPLICANT (Include City, State, ZIP)

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

Enter your E-Mail Address here:
IF REQUESTED BY OTHER THAN APPLICANT, SPECIFY NAME OF PARTY

CONTRACTOR ORDER NUMBER

DATE AVAILABLE FOR SAMPLING/INSP.

NOTE: Mark an “X” in appropriate blocks
MAIL CERTIFICATE AND FEE BILL TO
 APPLICANT

DISTRIBUTION INSTRUCTIONS

 OTHER (Specify)

 FAX  USPS  OVERNIGHT  EXPRESS GROUND MAIL  OTHER

TYPE OF PRODUCT  CANNED  FROZEN  DRIED  DEHYDRATED  OTHER

LOCATION OF PRODUCT (Name, Address, and Phone)

NAME OF PRODUCT
CASE MARKS (Specify in “Remarks” on reverse)

TYPE OF CASE
 NONE

 DOMESTIC

 OTHER (Specify)

 COMMERCIAL

PRODUCT PREVIOUSLY GRADED
 NO

 SPECIAL

FIELD OFFICE WHERE GRADED

 YES (If “Yes”, give Certificate Number)

REPORT RESULTS IMMEDIATELY AFTER GRADING TO

QUALITY REQUIREMENTS OF RECEIVER

 APPLICANT
 OTHER (Specify)
ADDITIONAL REQUIREMENTS (Check all that apply)

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

 “Officially Sampled” stamp on cases. Stamp this form when accomplished

 Condition of Container Examination (Federal or State Agencies)
Attach Form AD-748 or 741
 USDA Contracts–Country of Origin Certification and Traceability
Documents. (Plant Survey and Food Defense System Survey required) or

 Checkloading Required Date:_________________
 Unofficial Sample Submitted by Applicant. See terms and signature
request on reverse side of this form

PSA

 SECTION 8e IMPORT PRODUCT INSPECTION:
Importer of Record
Date of Entry
Port of Entry

Name of Vessel/Voyage No.

Customs Entry No.

Bill of Lading No.

Broker’s Reference No.

Harmonized Tariff Code

Container No.

Country of Origin

FCE No.

Port of Export

 EXPORT CERTIFICATE:
Port of Export
Port of Entry

Name of Vessel.

Voyage No.

Date of
Freezing

Freezing
Temp. °C.

Storage
Temp. °C.

 OTHER: PLEASE SPECIFY IN REMARKS
LOT NO.

LOT SIZE AND
DESCRIPTION

ADDITIONAL SAMPLE UNITS FOR:

 ANALYTICAL

NO. AND TYPE OF
CONTAINERS IN CASE

 USDA REVIEW

 EMBOSSED

 MONTHLY REVIEW

CODE MARKS IN LOT
 INK STAMPED  INK JET

OTHER

NO.
SAMPLES

 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
DATE

_____________________
________________________________________
ADDRESS OF SAMPLER OR FIELD OFFICE
OFFICIAL SAMPLER PRINT AND SIGN NAME
DRIVING
SAMPLING
STAMPING CONDITION CHECKLOADING
PRODUCT
OTHER
TOTAL
OVERTIME
(HRS)
(HRS)
(HRS)
(HRS)
(HRS)
EXAM (HRS)
(HRS)
HOURS
(HRS)

(OVER)

NIGHT
DIFF (HRS)

INSP
INT.

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  OTHER  Tray Pack

NUMBER PER CASE

CASE MARKINGS (if any)

LOT NO.

NO. SAMPLES

 EMBOSSED

CODE MARKS
 INK STAMPED  INK JET  OTHER

NO. CASES

LOCATION IN
WAREHOUSE

REMARKS

DATE

OFFICIAL SAMPLER PRINT AND SIGN NAME

ADDRESS OF FIELD OFFICE/INSPECTION POINT

The undersigned applies for inspection of the processed food products described in this application in accordance with the regulations of the Secretary of Agriculture (7 CFR). To the best of my knowledge
and belief, these containers are not from lots which have been previously inspected by the U.S. Department of Agriculture and are in no way the subject of controversy with any government agency.

NAME AND TITLE OF REQUESTOR

SIGNATURE OF REQUESTOR

Information in this application will be used in connection with performing an inspection on the product described in this application (7CFR 52). 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 0581-0234. The time required to complete this information collection is estimated to average 20 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, gender, 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 (9-15-10)

(Previous edition are to be destroyed)