Sanitary Certificate Request - Chile

Form Approved OMB No. 0581-NEW

U. S DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE SANITARY CERTIFICATE REQUEST-CHILE					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. This valid OMB control number for this collection is 0581-NEW. The time required to complete this information collection is estimated to average 12 minutes per response, including the ime for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection information.
I acknowledge that by checking this box that the information provided is factual and accurate.
1. CONTAC NAME		     					MAIL CERTIFICATE TO:
2. CUSTOMER NUMBER		     					7. COMPANY	     
3. BILLING REFERENCE		     					8. CONTACT	     
4. E-MAIL ADDRESS		     					9. STREET	     
5. CONTACT PHONE		     					10. CITY	     
6. FAX		     					11. STATE	     	12. ZIP	     
EXPORTER
13. NAME	     
14. ADDRESS	     
15. CITY, STATE	     
IDENTIFICATION OF DAIRY PRODUCTS
16. DESCRIPTION OF COMMODITY						     
17. KIND OF HEAT TREATMENT (HTST; PAST.)						     
18. TYPE OF PACKAGING						     
19. NUMBER OF PACKAGING UNITS						0
20. NET WEIGHT						     
21. REQUIRED TEMPERATURE DURING STORAGE AND TRANSPORTATION						     
22. EXPIRATION DATE						     
MANUFACTURER
23. PLANT NUMBER			     ;      ;      
PLACE OF LOADING
24. CITY, STATE			     
DESTINATION
25. DESTINATION				     
26. SENASA PERMIT NUMBER				     
27. SIGNATURE OF AGENT FOR APPLICANT							28. DATE
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.