Form DA-253 EU Health Certificate Request (Worksheet)

Form Approved OMB No. 0581-0283

U.S. DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE EUROPEAN UNION HEALTH CERTIFICATE REQUEST EU TRANSIT

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.

STORAGE FAXED CERTIFICATE*    ADDITIONAL CERTIFIED COPIES* *ADDITIONAL CHARGES APPLY

CONTACT INFORMATION

MAILING INFORMATION

CONTACT

     

COMPANY

     

AMS BILLING ACCOUNT

     

CONTACT

     

BILLING REFERENCE

     

STREET

     

E-MAIL ADDRESS

     

CITY

     

TELEPHONE

     

STATE

     

FAX

     

ZIP

     

I.1 CONSIGNOR

I.2 CERTIFICATE NUMBER

NAME

     

ADDRESS

     

I.3 CENTRAL COMPETENT AUTHORITY AGRICULTURAL MARKETING SERVICE

CITY

     

STATE

     

POSTAL CODE

     

TEL.Nº

     

I.5 CONSIGNEE

I.6 PERSON RESPONSIBLE FOR LOAD IN EU

NAME

     

NAME

     

ADDRESS

     

ADDRESS

     

POSTAL CODE

     

TEL.Nº

     

POSTAL CODE

     

TEL.Nº

     

I.9 COUNTRY OF DESTINATION ISO CODE   

I.11 PLACE OF ORIGIN

I.12 PLACE OF DESTINATION

NAME

APPROVAL NUMBER

ADDRESS

APPROVAL CODE

     

CUSTOM WAREHOUSE

     

     

     

NAME

     

     

     

     

ADDRESS

     

     

     

     

POSTAL CODE

     

I.13 PLACE OF LOADING      

I.14 DATE OF DEPARTURE

     

DATE OF ARRIVAL      

I.15 MEANS OF TRANSPORT

I.16 ENTRY BIP IN EU

ID      

DOC REF      

     

I.18 DESCRIPTION OF COMMODITY      

I.19 COMMODITY CODE (HS CODE)      

I.20 QUANTITY (NET/GROSS WEIGHT)

I.21 TEMPERATURE OF PRODUCT

GROSS WEIGHT

     

I.23 IDENTIFICATION OF

NET WEIGHT

     

CONTAINER      

I.22 NUMBER OF PACKAGES

     

SEAL NUMBER      

I.24 TYPE OF PACKAGING

     

I.25 COMMODITIES CERTIFIED FOR: HUMAN CONSUMPTION

I.27 FOR IMPORT OR ADMISSION TO THE EU

I.26 FOR TRANSIT THROUGH EU TO 3RD COUNTRY

3RD COUNTRY ISO CODE

  

I.28 IDENTIFICATION OF THE COMMODITIES      

RAW MILK PRODUCT

SPECIES (SCIENTIFIC NAME)

FDA PLANT APPROVAL NUMBER

NUMBER OF PACKAGES

NET WEIGHT

BATCH NUMBER(S)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

II.d PRODUCED ON/BETWEEN

     

AND

     **

**FILLED FOR BETWEEN; EMPTY FOR ON

SIGNATURE

DATE

DA-253 (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, gender, religion, age, disability, sexual orientation, marital or family status, political beliefs, parental status, or protected genetic information. (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 USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Washington, DC 20250-9410 or call 202-720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.