DA-248 Sanitary Certificate Request - Tunisia

Form
U. S DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

SANITARY CERTIFICATE REqUEST

OMB No.0581-0283

According to the paperuvork 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.

TYPE

Faxed Certificate"
0 Additional Copies' 'additional charses applv
Tunisia
I acknowledse that by checking this box that the information provided is factual and accurate.

CONTACT INFORMATION

MAILING INFORMATION

1. CONTACT NAME

7. COMPANY

2. AMS BILLING ACCT.

8. CONTACT

3. BILLING REFERENCE

9. STREET

4. E-MAIL

10. clTY

ADDRESS

5. CONTACT PHONE

11. STATE

6. FAX

12.ZtP

CONSIGNOR

13. NAME
14. ADDRESS
15. C|rY/STATE
CONSIGNEE

16. NAME
17. ADDRESS
18. COUNTRY CODE

TN

IDENTIFICATION OF DAIRY PRODUCTS
1.9. DESCRIPTION OF COMMODITY

20. TYPE OF PACKAGING

21. NUMBER OF PACKAGING UNITS
22. NET WEIGHT

!b

MANUFACTURER

23. PLANT NUMBER

LOT CODE

QUANITY

NET WEIGHT

PROD. DATE

SHIPMENT !NFORMATION

24. PLACE OF LOADING
SIGNATURE (for foxed or moiled copies)

25. DATE

**Forfastest processing, please attach this form and a
DA-248

PDF

shipping label in an emailto [email protected].

(Or/21t6l

programoractivilyconductedorfundedbyUSDA(notall

basesapplytoallprograms)

Remediesmdcomplaintfilingdeadlinesvarybyprogramorincident

rnay be made available in languages other than English

om, AD-3027, found online at hftp://w.ascr.usda.gov/complaint filing cust.html and at
quested in the fom. To request a copy of the complaint fom, call (866) 632-9992. Submit
istant Secretary forCivil Rights 1400 Independence Avenue, SW Washington, D.C. 20250_
ty provider, employer, and lender.