Free 50437.pdf - Indiana

Division of Entomology & Plant Pathology 402 West Washington Street, Room W-290 Indianapolis, Indiana 46204 Phone: (317) 232-4120 Fax: (317) 232-2649

STATE OF INDIANA: REQUEST FOR PHYTOSANITARY CERTIFICATE
IMPORTANT NOTICE: Any intentional false statement or misrepresentation on the Phytosanitary Certificate is a violation of federal law, punishable by a fine and/or imprisonment. (Ref. 18 U.S.C. s1001)

Applicant Must Complete in Entirety: Date of Application: __________________________ Contact Name: ______________________________ Contact Phone: ______________________________ Shipment Date: ______________________________

For State Office Use Only: _PC_________________________ ____________________________ ____________________________

Fumigation and Disinfection Treatment Information: *Please List Active Ingredients, Do Not List Trade Names Treatment Date: __________________________________ Duration of Treatment:________________________ Chemical(s)* used: _______________________________ Concentration: ______________________________ Exporter's Name: _____________________________ Importer's Name: ______________________________ Address: _____________________________________ Address: ______________________________________ _____________________________________ _____________________________________ ______________________________________ ______________________________________

Total Quantity & Name of Product: _____________________________________________________________ Botanical Name: ____________________________________________________________________________ No. & Description of Packages: ________________________________________________________________ Distinguishing Marks: ________________________________________________________________________ State(s) of Origin of Product: _____________________ Means of Conveyance: _________________________ Point of Entry: _________________________________ Where Product is Now: _________________________ Phytosanitary Inspection Info [List Producer, Year grown, Variety Number(s) and Field Number(s)] __________________________________________________________________________________________ __________________________________________________________________________________________ Billing Name: (If different from exporter) ________________________________________ Address: ______________________________________ ______________________________________ Ph. #_________________________________________ Contact Person_________________________________ Method of Return: Send Certificate to: (If different from exporter) _________________________________________ Address: _________________________________ _________________________________ Ph. # ____________________________________ Contact Person_____________________________

FEDERAL EXPRESS, UPS, or REGULAR MAIL
(For Federal Express or UPS returns, please include Account Number of a Recipient or Third Party)

Service Requested : _______________________________________________ Account #____________________________ (Circle: Recipient or Third Party) Applicant Signature: _______________________________________
State Form 50437 (8-01) Approved by State Board of Accounts, 2001