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.
TYPE
Faxed
Certificate*
0
Additional Copies*
*additional charges apply
I acknowledge that by checking this box that the information
provided is factual and accurate.
contact
information
mailing
information
CONTACT
NAME
7.
COMPANY
AMS
BILLING ACCT.
8.
CONTACT
BILLING
REFERENCE
9.
STREET
E-MAIL
ADDRESS
10.
CITY
CONTACT
PHONE
11.
STATE
FAX
12.
ZIP
CONSIGNOR
13.
NAME
14.
ADDRESS
15.
CITY/STATE
CONSIGNEE
16.
NAME
17.
ADDRESS
18.
COUNTRY CODE
PE
IDENTIFICATION
OF DAIRY PRODUCTS
19.
DESCRIPTION OF COMMODITY
20.
PRODUCT IDENTIFICATION
21.
TYPE OF PACKAGING
22.
NUMBER OF PACKAGING UNITS
23.
NET WEIGHT
24.
PASTEURIZED?
YES
25.
INDIVIDUALLY PACKED?
YES
26.
SENASA PERMIT NO.
MANUFACTURER
27.
PLANT NUMBER
SIGNATURE
(for faxed or mailed copies)
29.
DATE
January 16, 2021
**For
fastest processing, please attach this form and a PDF shipping label
in an email to [email protected].
DA-247
(01/2013)
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.