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No phytosanitary certificate can be issued until an application is completed (7 CFR 365)

See reverse for additional OMB Information.

FORM APPROVED
OMB NO. 0579-0052, 0094, and 0240

FOR OFFICIAL USE ONLY

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
PLANT PROTECTION AND QUARANTINE

PLACE OF ISSUE

PHYTOSANITARY CERTIFICATE

NO.:

TO: THE PLANT PROTECTION ORGANIZATION(S) OF

FPC

DATE INSPECTED

CERTIFICATION
This is to certify that the plants, plant product, or other regulated articles described herein have been inspected and/or tested according to appropriate official procedures and
are considered to be free from the quarantine pests, specified by the importing contracting party, and to conform with the current phytosanitary requirements of the importing
contracting party including those for regulated non-quarantine pests.

DISINFESTATION AND/OR DISINFECTION TREATMENT
1. DATE

2. TREATMENT

3. CHEMICAL (active ingredient)

4. DURATION AND TEMPERATURE

5. CONCENTRATION

6. ADDITIONAL INFORMATION

DESCRIPTION OF THE CONSIGNMENT
7. NAME AND ADDRESS OF THE EXPORTER

8. DECLARED NAME AND ADDRESS OF THE CONSIGNEE

9. NAME OF PRODUCE AND QUANTITY DECLARED

10. BOTANICAL NAME OF PLANTS

11. NUMBER AND DESCRIPTION OF PACKAGES

12. DISTINGUISHING MARKS

13. PLACE OF ORIGIN

14. DECLARED MEANS OF CONVEYANCE

15. DECLARED POINT OF ENTRY

WARNING: Any alteration, forgery, or unauthorized use of this phytosanitary certificate is subject to civil penalties of up to $250,000 (7 U.S.C. Section 7734(b)) or punishable by a fine of
not more than $10,000, or imprisonment of not more than 5 years, or both (18 U.S.C. Section 1001).

ADDITIONAL DECLARATION

16. DATE ISSUED

17. NAME OF AUTHORIZED OFFICER (Type or Print)

18. SIGNATURE OF AUTHORIZED OFFICER

No liability shall attach to the United States Department of Agriculture or to any officer or representative of the Department with respect to this certificate.
PPQ FORM 577 FEB 2001

Previous editions are obsolete after 6/30/01

L'inspecteur de Service de la Protection des végétaux dont la signature figure au recto, certifie que les
végétaux, produits végétaux ou autres articles réglementés décrits ci-dessus ont été inspectés et/ou testés
suivant des procédures officielles appropriées et estimés exempts d'organismes de quarantaine comme
spécifié par la partie contractante importatrice; et qu’ils sont jugés conformes aux exigences phytosanitaires
en vigueur de la partie contractante importatrice, y compris à celle concernant les organismes réglementés
non de quarantaine. Note: Le Départment de l'Agriculture des États-Unis, ses agents ou reprèsentants ne
peuvent encourir aucune responsabilité quant à la teneur de ce certificat.

El Inspector de Cuarentena Agrícola cuya firma aparece al reverso, certifica que las plantas, productos
vegetales o otros artículos reglamentados descritos aquí se han inspeccionado y/o sometido a ensayo de
acuerdo con los procedimientos oficiales adecuados y se considera que están libres de las plagas
cuarentenarias especificadas por la parte contratante importadora y que cumplen los requisitos fitosanitarios
vigentes de la parte contratante importadora, incluidos los relativos a las plagas no cuarentenarias
reglamentadas. Nota: El Ministerio de Agricultura de los Estados Unidos, ni ningún funcionario ni
representante de dicho Ministerio asume responsabilidad alguna con respecto a este certificado.

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 numbers for this information collection are 0579-0052, 0094, and 0240. The time required
to complete this information collection is estimated to average 1.2 hours 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.

PPQ FORM 577 (Reverse Parts 1 and 2)

1. LOCATION OF ARTICLES

EXPORT INSPECTION DATA (To be filled in by Authorized Officer)
2. % OF MATERIALS EXAMINED

3. % OF MATERIALS INFESTED

4. FINDING AND/OR TREATMENT GIVEN

5. SIGNATURE

PPQ FORM 577 (Reverse Part 4)

6. DATE AND TIME INSPECTED