Form PPQ 572 Form PPQ 572 Form Application for Inspection & Certification for Domestic

According to the Paperwork 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 valid OMB control number for this information collection is 0579-0052. The time required to complete
this information collection is estimated to average .20 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.
No Phytosanitary Export Certificate can be issued until an application is completed (7 CFR 353).
U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALT H INSPECTION SERVICE
PLANT PROTECTION AND QUARANTINE

APPLICATION FOR INSPECTION AND CERTIFICATION OF DOMESTIC
PLANT S AND PLANT PRODUCTS FOR EXPORT
1. NAME AND ADDRESS OF EXPORTER

OMB APPROVED
0579-0052
Exp.: XX/XXXX

INSTRUCTIONS: APPLICANT - Forward original
to the Officer in Charge where inspections,
treatment, and certification will be given (Item 4).
Complete items 1 through 11.
OFFICER - Complete items 12 through 17.

3. NAME AND ADDRESS OF APPLICANT (or exporters agent)

AREA CODE AND PHONE NUMBER

2. NAME AND ADDRESS OF FOREIGN CONSIGNEE

4. PLACE WHERE ARTICLES WILL BE MADE AVAILABLE FOR INSPECTION
AND/OR TREATMENT AND CERTIFICATION(Port and location)

6. PORT OF EXPORT

5. APPROX. DATE OF DEPARTURE

7. DESCRIPTION OF ARTICLES TO BE CERTIFIED

a.
QUANTITY AND NAME
OF PRODUCE AND 
BOTANICAL NAME

b.
NUMBER AND 
DESCRIPTION OF
PACKAGES

c.
DISTINGUISHING 
MARKS

d.
CERTIFIED ORIGIN

8. DECLARED MEANS OF CONVEYANCE

I certify that the origin (place where grown) of the articles listed is as
represented.
9. DECLARED POINT OF ENTRY

10. SIGNATURE (applicant or exporters agents)

11. DATE

EXPORT INSPECTION DATA - (To be filled in by Plant Protection and Quarantine Officer)
12. LOCATION OF ARTICLES

13. % OF MATERIALS EXAMINED

14. % OF MATERIALS INFESTED

15. FINDINGS AND/OR TREATMENT GIVEN (Use reverse if necessary)

16. SIGNATURE

PPQ FORM 572
APR 2020

17. DATE AND TIME INSPECTED