DA-246 Sanitary Certificate Request - Cuba

OMB No.0581-028

Form

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 0581-0283. The time required to complete this information
collection is estimated to average 12 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 information.

U. S DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

SANITARY CERTIFICATE REQUEST

TYPE

Faxed

Cuba

certificate-

0 Additional

Copies'

*additional charses applv

that by checking this box that the information provided

1. CONTACT NAME

is factual and accurate.
MAILING INFORMATION
7. COMPANY

2. AMS BILLING ACCT.

8. CONTACT

3. BILLING REFERENCE

9. STREET

4. E-MAIL

10. crrY

I acknowledge

CONTACT INFORMATION

ADDRESS

5. CONTACT PHONE

11. STATE

6. FAX

1,2.ZtP

CONSIGNOR

13. NAME
14. ADDRESS

1s. C|TY/STATE
CONSIGNEE

16. NAME
17. ADDRESS
18. COUNTRY CODE

CU

IDENTIFICATION OF DAIRY PRODUCTS

19. DESCRIPTION OF COMMODITY
20. KIND OF HEAT TREATMENT (HTST; PASTEURIZED)
21. TYPE OF PACKAGING

22. NUMBER OF PACKAGING UNITS
23. NET WEIGHT
24. REQUIRED TEMPERATURE DURING STORAGE AND

tb

TRANSPORTATION

25.EXPIRATION DATE
MANUFACTURER

26. PLANT NUMBER
SHIPMENT INFORMATION

27. ENTRY PORT
SIGNATURE (for foxed or moiled copies)

28. DATE

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