Form FV-356 Application for Inspection & Certificate of Sampling

REPRODUCE LOCALLY.  Include form number and edition date on all reproductions.                                                                           OMB APPROVED NO. 0581-0125

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

     

CONTRACTOR ORDER NUMBER

                  

DATE AVAILABLE FOR SAMPLING/INSP.

     

NOTE:  Mark an “X” in appropriate blocks

MAIL CERTIFICATE AND FEE BILL TO

  APPLICANT                  OTHER (Specify)

MAILING INSTRUCTIONS

 FEDEX  UPS  AIR MAIL (JAPAN)  EXPRESS MAIL  OTHER

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

NAME OF PRODUCT     

 LOCATION OF PRODUCT (Name, Address, and Phone)

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 (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	 Checkloading  Required  Date:_____________________
 USDA Contracts–Country of Origin Certification and Traceability Documents. (Plant Survey and Food Defense Survey required.)	 Unofficial Sample Submitted by Applicant.

Section 8e Import Product Inspection:

Importer of Record	Date of Arrival	Port of Entry	Vessel No.	Customs Entry No.	Bill of Lading No.
Broker’s Reference No.	FCE No.	Port of Export	Harmonized Tariff Code	Consignee No.	Country of Origin

Export Certificate:

Port of Export

Port of Entry

Vessel No.

Voyage No.

Date of Freezing

Freezing Temp. °C.

Storage Temp. °C.

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)

INSP INT.

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

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 0581-0125. 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, 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 (XX-XX) 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 (XX-XX) (REVERSE)