Form NSHS Version 3.2 NSHS Version 3.2 Accreditation Application 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. The OMB control number for
this information collection is 0579-0130. The time required to complete this information collection is estimated to
average 2 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.

OMB Approved
0579-0130
Exp.: XX/XXXX

VERSION 3.Ϯ
MARCH Ϯϵ, 2017

ACCREDITATION APPLICATION FORM

TABLE OF CONTENTS
APPLICANT DETAILS . . . . . . . . . . 2
ACCREDITATION OPTIONS . . . . . 3
TESTING SITE LOCATIONS . . . . . . 3 - 6
OPTION 1 . . . . . . . . . . . . . . . . . . . 7
OPTION 2 . . . . . . . . . . . . . . . . . . . 8 - 12
OPTION 3 . . . . . . . . . . . . . . . . . . . 13
OPTION 4 . . . . . . . . . . . . . . . . . . . 14
APPLICATION SUBMISSION . . . . . 15

APPLICANT DETAILS
COMPANY/ORGANIZATION TO BE ACCREDITED
Legal Name Click or tap here to enter text
Street Address
City

State

Telephone Number

ZIP Code
Fax Number

E-mail Address
Website URL

CONTACT PERSON
Full Name Click or tap here to enter text
WŽƐŝƟŽŶ
Street Address
City

State

Telephone Number

ZIP Code
Fax Number

E-mail Address

TYPE OF COMPANY/ORGANIZATION
‫ ܆‬Seed Company
‫ ܆‬Private Seed Company
‫ ܆‬Private Agricultural Consultants
‫ ܆‬ĞƌƟĮĐĂƟŽŶŐĞŶĐLJ
‫ ܆‬State/County Agency
‫ ܆‬University Laboratory
‫ ܆‬Other

Page 2 of 15

ACCCREDITATION OPTIONS
SITE DEFINITIONS

OPTION 1: Seed Health Testing
• Laboratory-based program to test for plant pathogens in seeds.

OPTION 2: Phytosanitary Inspection
• Disease Inspection of plants grown to produce seed in the field, nursery, or
greenhouse.

OPTION 3: Seed Sampling for Seed Health Testing
• Sampling seeds that require laboratory seed health tests.

OPTION 4: Visual Inspection of Seed for Phytosanitary Certification
• Visual inspection of seed shipments at exporter's facility prior to issuance of

phytosanitary certificates.

TEST SITE LOCATIONS TO BE ACCREDITED
SITE LOCATION

1

^ŝƚĞ>ŽĐĂƟŽŶEĂŵĞ (State) Click or tap here to enter text
Street Address
City
Contact Person

ZIP Code

State
WŽƐŝƟŽŶ

Telephone Number
E-mail Address
ĐĐƌĞĚŝƚĂƟŽŶ ‫ ܆‬OPTION 1

‫ ܆‬OPTION 2

‫ ܆‬OPTION 3

‫ ܆‬OPTION 4

Page 3 of 15

TEST SITE LOCATIONS TO BE ACCREDITED
SITE LOCATION

(CONTINUED)

2

^ŝƚĞ>ŽĐĂƟŽŶEĂŵĞ (State) Click or tap here to enter text
Street Address
City

ZIP Code

State

Contact Person

WŽƐŝƟŽŶ

Telephone Number
E-mail Address
ĐĐƌĞĚŝƚĂƟŽŶ ‫ ܆‬OPTION 1

SITE LOCATION

‫ ܆‬OPTION 2

‫ ܆‬OPTION 3

‫ ܆‬OPTION 4

3

^ŝƚĞ>ŽĐĂƟŽŶEĂŵĞ (State) Click or tap here to enter text
Street Address
City

State

Contact Person

ZIP Code
WŽƐŝƟŽŶ

Telephone Number
E-mail Address
ĐĐƌĞĚŝƚĂƟŽŶ ‫ ܆‬OPTION 1
SITE LOCATION

‫ ܆‬OPTION 2

‫ ܆‬OPTION 3

‫ ܆‬OPTION 4

4

^ŝƚĞ>ŽĐĂƟŽŶEĂŵĞ (State) Click or tap here to enter text
Street Address
City
Contact Person

ZIP Code

State
WŽƐŝƟŽŶ

Telephone Number
E-mail Address
ĐĐƌĞĚŝƚĂƟŽŶ ‫ ܆‬OPTION 1

‫ ܆‬OPTION 2

‫ ܆‬OPTION 3

‫ ܆‬OPTION 4
Page 4 of 15

TEST SITE LOCATIONS TO BE ACCREDITED
SITE LOCATION

(CONTINUED)

5

^ŝƚĞ>ŽĐĂƟŽŶEĂŵĞ (State) Click or tap here to enter text
Street Address
City

ZIP Code

State

Contact Person

WŽƐŝƟŽŶ

Telephone Number
E-mail Address
ĐĐƌĞĚŝƚĂƟŽŶ ‫ ܆‬OPTION 1

SITE LOCATION

‫ ܆‬OPTION 2

‫ ܆‬OPTION 3

‫ ܆‬OPTION 4

6

^ŝƚĞ>ŽĐĂƟŽŶEĂŵĞ (State) Click or tap here to enter text
Street Address
City

State

Contact Person

ZIP Code
WŽƐŝƟŽŶ

Telephone Number
E-mail Address
ĐĐƌĞĚŝƚĂƟŽŶ ‫ ܆‬OPTION 1
SITE LOCATION

‫ ܆‬OPTION 2

‫ ܆‬OPTION 3

‫ ܆‬OPTION 4

7

^ŝƚĞ>ŽĐĂƟŽŶEĂŵĞ (State) Click or tap here to enter text
Street Address
City
Contact Person

ZIP Code

State
WŽƐŝƟŽŶ

Telephone Number
E-mail Address
ĐĐƌĞĚŝƚĂƟŽŶ ‫ ܆‬OPTION 1

‫ ܆‬OPTION 2

‫ ܆‬OPTION 3

‫ ܆‬OPTION 4
Page 5 of 15

TEST SITE LOCATIONS TO BE ACCREDITED

(CONTINUED)

SITE LOCATION
^ŝƚĞ>ŽĐĂƟŽŶEĂŵĞ (State) Click or tap here to enter text
Street Address
City

ZIP Code

State

Contact Person

WŽƐŝƟŽŶ

Telephone Number
E-mail Address
ĐĐƌĞĚŝƚĂƟŽŶ ‫ ܆‬OPTION 1

‫ ܆‬OPTION 2

‫ ܆‬OPTION 3

‫ ܆‬OPTION 4

SITE LOCATION
^ŝƚĞ>ŽĐĂƟŽŶEĂŵĞ (State) Click or tap here to enter text
Street Address
City

State

Contact Person

ZIP Code
WŽƐŝƟŽŶ

Telephone Number
E-mail Address
ĐĐƌĞĚŝƚĂƟŽŶ ‫ ܆‬OPTION 1

‫ ܆‬OPTION 2

‫ ܆‬OPTION 3

‫ ܆‬OPTION 4

SITE LOCATION
^ŝƚĞ>ŽĐĂƟŽŶEĂŵĞ (State) Click or tap here to enter text
Street Address
City
Contact Person

ZIP Code

State
WŽƐŝƟŽŶ

Telephone Number
E-mail Address
ĐĐƌĞĚŝƚĂƟŽŶ ‫ ܆‬OPTION 1

‫ ܆‬OPTION 2

‫ ܆‬OPTION 3

‫ ܆‬OPTION 4
Page 6 of 15

KWd/KEϭ͗^ĞĞĚ,ĞĂůƚŚdĞƐƟŶŐ
ACCREDITATION FEES WORKSHEET

1

Site #

Pathogen

#

Click or tap here to enter text

FIND NSHS METHODS CODES: SEEDHEALTH.ORG

Test Code

ĐĐƌĞĚŝƚĂƟŽŶ&ĞĞ

Enter Code $3,000 minimum fee: 6 tests or less

2
3
4
5
6
7

ΨϮϱϬĨŽƌĞĂĐŚĂĚĚŝƟŽŶĂůƚĞƐƚ

8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

TOTAL FEES $dŽƚĂů&ĞĞƐĨŽƌKƉƟŽŶϭ
0.00
Page 7 of 15

KWd/KEϮ͗WŚLJƚŽƐĂŶŝƚĂƌLJ/ŶƐƉĞĐƟŽŶ
ACCREDITATION FEES WORKSHEET
Site #

(ADDITIONAL WORKSHEETS PAGES 9-12)

Site Name (State) Enter Site Name Here

List of Crops:
1

ĐĐƌĞĚŝƚĂƟŽŶ&ĞĞ

Click or tap here to enter name of crop

$2000 ƉĞƌƐŝƚĞůŽĐĂƟŽŶ

2

ΨϮϱϬĨŽƌĞĂĐŚĂĚĚŝƟŽŶĂůĐƌŽƉ

3
4
5
6
Site #

Site Name (State) Enter Site Name Here

List of Crops:
1

ĐĐƌĞĚŝƚĂƟŽŶ&ĞĞ

Click or tap here to enter name of crop

$2000 ƉĞƌƐŝƚĞůŽĐĂƟŽŶ

2

ΨϮϱϬĨŽƌĞĂĐŚĂĚĚŝƟŽŶĂůĐƌŽƉ

3
4
5
6
TOTAL FEES $ dŽƚĂů&ĞĞƐĨŽƌKƉƟŽŶϮ
0.00

LABORATORY PROVIDING DIAGNOSTIC SERVICES
Laboratory Name Click or tap here to enter text
Contact Person

WŽƐŝƟŽŶ

Street Address
City
Telephone

State
Fax

ZIP Code
Email Address

Page 8 of 15

KWd/KEϮ͗WŚLJƚŽƐĂŶŝƚĂƌLJ/ŶƐƉĞĐƟŽŶ
ACCREDITATION FEES WORKSHEET ( CON T I N UE D)
Site #

Site Name (State) Enter Site Name Here

List of Crops:
1

ĐĐƌĞĚŝƚĂƟŽŶ&ĞĞ

Click or tap here to enter name of crop

2

$2000 ƉĞƌƐŝƚĞůŽĐĂƟŽŶ
ΨϮϱϬĨŽƌĞĂĐŚĂĚĚŝƟŽŶĂůĐƌŽƉ

3
4
5
6
7
8
9
10
Site #

Site Name (State) Enter Site Name Here

List of Crops:
1
2

Click or tap here to enter name of crop

ĐĐƌĞĚŝƚĂƟŽŶ&ĞĞ
$2000 ƉĞƌƐŝƚĞůŽĐĂƟŽŶ
ΨϮϱϬĨŽƌĞĂĐŚĂĚĚŝƟŽŶĂůĐƌŽƉ

3
4
5
6
7
8
9
10

Page 9 of 15

KWd/KEϮ͗WŚLJƚŽƐĂŶŝƚĂƌLJ/ŶƐƉĞĐƟŽŶ
ACCREDITATION FEES WORKSHEET ( CON T I N UE D)
Site #

Site Name (State) Enter Site Name Here

List of Crops:
1

ĐĐƌĞĚŝƚĂƟŽŶ&ĞĞ

Click or tap here to enter name of crop

2

$2000 ƉĞƌƐŝƚĞůŽĐĂƟŽŶ
ΨϮϱϬĨŽƌĞĂĐŚĂĚĚŝƟŽŶĂůĐƌŽƉ

3
4
5
6
7
8
9
10
Site #

Site Name (State) Enter Site Name Here

List of Crops:
1
2

Click or tap here to enter name of crop

ĐĐƌĞĚŝƚĂƟŽŶ&ĞĞ
$2000 ƉĞƌƐŝƚĞůŽĐĂƟŽŶ
ΨϮϱϬĨŽƌĞĂĐŚĂĚĚŝƟŽŶĂůĐƌŽƉ

3
4
5
6
7
8
9
10

Page 10 of 15

KWd/KEϮ͗WŚLJƚŽƐĂŶŝƚĂƌLJ/ŶƐƉĞĐƟŽŶ
ACCREDITATION FEES WORKSHEET ( CON T I N UE D)
Site #

Site Name (State) Enter Site Name Here

List of Crops:
1

ĐĐƌĞĚŝƚĂƟŽŶ&ĞĞ

Click or tap here to enter name of crop

2

$2000 ƉĞƌƐŝƚĞůŽĐĂƟŽŶ
ΨϮϱϬĨŽƌĞĂĐŚĂĚĚŝƟŽŶĂůĐƌŽƉ

3
4
5
6
7
8
9
10
Site #

Site Name (State) Enter Site Name Here

List of Crops:
1
2

Click or tap here to enter name of crop

ĐĐƌĞĚŝƚĂƟŽŶ&ĞĞ
$2000 ƉĞƌƐŝƚĞůŽĐĂƟŽŶ
ΨϮϱϬĨŽƌĞĂĐŚĂĚĚŝƟŽŶĂůĐƌŽƉ

3
4
5
6
7
8
9
10

Page 11 of 15

KWd/KEϮ͗WŚLJƚŽƐĂŶŝƚĂƌLJ/ŶƐƉĞĐƟŽŶ
ACCREDITATION FEES WORKSHEET ( CON T I N UE D)
Site #

Site Name (State) Enter Site Name Here

List of Crops:
1

ĐĐƌĞĚŝƚĂƟŽŶ&ĞĞ

Click or tap here to enter name of crop

2

$2000 ƉĞƌƐŝƚĞůŽĐĂƟŽŶ
ΨϮϱϬĨŽƌĞĂĐŚĂĚĚŝƟŽŶĂůĐƌŽƉ

3
4
5
6
7
8
9
10
Site #

Site Name (State) Enter Site Name Here

List of Crops:
1
2

Click or tap here to enter name of crop

ĐĐƌĞĚŝƚĂƟŽŶ&ĞĞ
$2000 ƉĞƌƐŝƚĞůŽĐĂƟŽŶ
ΨϮϱϬĨŽƌĞĂĐŚĂĚĚŝƟŽŶĂůĐƌŽƉ

3
4
5
6
7
8
9
10

Page 12 of 15

KWd/KEϯ͗^ĞĞĚ^ĂŵƉůŝŶŐĨŽƌ^ĞĞĚ,ĞĂůƚŚdĞƐƟŶŐ
ACCREDITATION FEES WORKSHEET
Site #

Site Name (State)

#

Enter site name here

List of Crops
Name of crop here

# of Inspectors
Enter #

TOTAL FEES $1000
$ 0.00Flat Fee

Page 13 of 15

KWd/KEϰ͗sŝƐƵĂů/ŶƐƉĞĐƟŽŶŽĨ^ĞĞĚĨŽƌWŚLJƚŽƐĂŶŝƚĂƌLJĞƌƟĮĐĂƟŽŶ

ACCREDITATION FEES WORKSHEET
Site #

Site Name (State)

List of Crops

#

Enter site name here

# of Inspectors

Name of crop here

Enter #

ΨϭϬϬϬ&ůĂƚ&ĞĞ
TOTAL FEES $
0.00

LABORATORY PROVIDING DIAGNOSTIC SERVICES
Laboratory Name Click or tap here to enter text
Contact Person

WŽƐŝƟŽŶ

Street Address
City

State

Telephone

Fax

ZIP Code
Email Address

Page 14 of 15

APPLICATION SUBMISSION CHECKLIST
STEP 1
‫ ܆‬Submit a non-refundable $400 deposit check payable to USDA
‫^ ܆‬ŝŐŶĂŶĚ^ƵďŵŝƚĂůůĐŽŵƉůĞƚĞĚĐĐƌĞĚŝƚĂƟŽŶƉƉůŝĐĂƟŽŶĨŽƌŵƐ to:

Sarika Negi
ĐĐƌĞĚŝƚĂƟŽŶĂŶĚĞƌƟĮĐĂƟŽŶWŽůŝĐLJDĂŶĂŐĞƌ
Plant Health Programs – Export Services
4700 River Road, Unit 131
Riverdale, MD 20737-1236

Tele: 301.851.2349
E-mail: [email protected]

STEP 2
‫ ܆‬Submit a non-refundable $600 deposit check payable to Iowa State University
‫ ܆‬Submit a copy of your Quality Manual
‫ ܆‬Submit a copy of all completed AccƌĞĚŝƚĂƟŽŶƉƉůŝĐĂƟŽŶĨŽƌŵƐƚŽ͗

Gary Munkvold
E^,^ĚŵŝŶŝƐƚƌĂƟǀĞhŶŝƚ
160 Seed Science Center
Iowa State University
2115 Osborn Drive
Ames, IA 50011

Tele: 515.294.7560
Fax: 515.294.2014
E-mail: [email protected]
Website URL: seedhealth.org

STEP 3
hƉŽŶĂƉƉƌŽǀĂůŽĨLJŽƵƌĂƉƉůŝĐĂƟŽŶďLJh^-W,/^͕LJŽƵǁŝůůďĞĐŽŶƚĂĐƚĞĚďLJƚŚĞE^,^ĐĐƌĞĚŝƚĂƟŽŶ
hŶŝƚǁŝƚŚĨƵƌƚŚĞƌŝŶƐƚƌƵĐƟŽŶƐŽŶƚŚĞĂĐĐƌĞĚŝƚĂƟŽŶƉƌŽĐĞƐƐĂŶĚďŝůůŝŶŐĨŽƌƚŚĞƚŽƚĂůĂĐĐƌĞĚŝƚĂƟŽŶĨĞĞ
and auditor fees.

‫ ܆‬KPTION 1
‫ ܆‬OPTION 2
‫ ܆‬OPTION 3
‫ ܆‬OPTION 4

Total fees from ĐĐƌĞĚŝƚĂƟŽŶOPTION 1:
Total fees from AccreditĂƟŽŶ OPTION 2:
Total fees from ĐĐƌĞĚŝƚĂƟŽŶ OPTION 3:
Total fees from ĐĐƌĞĚŝƚĂƟŽŶ OPTION 4:

$ Total or N/A

Page ϳ
Page ϴ
Page ϭϯ
Page ϭϰ

$ Total or N/A
ΨdŽƚĂůŽƌEͬ

TOTAL FEE^
** If reƋƵĞƐƟŶŐƚĞƐƚƐĨƌŽŵďŽƚŚOPTION 1 & OPTION 2: Subtract $1000
:h^dTOTAL

ΨdŽƚĂůŽĨEͬ
$ Total Fees
ΎΎ^ƵďƚƌĂĐƚΨϭϬϬϬ

ĚũƵƐƚĞĚTotal &ĞĞƐ

STEP 4
‫ ܆‬ŽŵƉĂŶLJŽƌKƌŐĂŶŝnjĂƟŽŶƵƚŚŽƌŝnjĞĚ^ŝŐŶĂƚƵƌĞ

SIGNATURE: ____________________________________________________________________
Legal Name:_______________________ Title: _____________________ Date: ____________
Page 15 of 15