EU Health Certificate Worksheet

Export Health Certificate Request Forms

EU Health Certificate Worksheet 100312

Export Certificates

OMB: 0581-0283

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OMB No. 0581-NEW

EU Health Certificate Worksheet

Applicant (Company Name)      

Mail Certificate to

Applicant Number

     

Contact

     

Customer Ref

     

Company

     

Contact

     

Street

     

E-Mail Address

     

City

     

Telephone

     

State

     

Fax

     

Zip

     

Faxed Certificate*

      Additional Certified Copies*

*additional charges apply

I.1 Consignor

Name

     

Address

     

Tel.Nº      

I.2 Certificate reference number

     

1.2.a

I.3 Central Competent Authority

AMS

I.4 Local competent Authority


I.5 Consignee

Name

     

Address

     

Postal code      

Tel.Nº      

I.6

I.7 Country of origin

ISO code

I.8 Region of origin

Code

I.9 Country of destination

ISO code

I.10

     

     



     

     

I.11 Place of origin


I.12

Name

Approval number      

     

Address

     

I.13 Place of loading

     

I.14 Date of departure

     

I.15 Means of transport

I.16 Entry BIP in EU

Aeroplane

Ship

Railway wagon

     

Road vehicle

Other

Identification:      

I.17

Documentation reference:      

I.18 Description of commodity

I.19 Commodity code (HS code)

     

     


I.20 Quantity (Net/Gross Weight)


     

I.21 Temperature of product

I.22 Number of packages


Ambient

Chilled

Frozen

     

I.23 Identification of container/Seal number

I.24 Type of packaging

     

     

I.25 Commodities certified for:




Human consumption



I.26 For transit through EU to 3rd country

3rd country       ISO code      

I.27 For import or admission into EU


I.28 Identification of the commodities

     

Species

Approval number of establishment



(Scientific name)

manufacturing plant

Number of packages

Net weight

Batch number

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

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-NEW. The time required to complete this information collection is estimated to average 12 minutes/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.


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.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorKen Vorgert
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File Created2021-01-24

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