EU Health Certificate Worksheet

OMB No. 0581-NEW

EU Health Certificate Worksheet

Applicant (Company Name)      		Mail Certificate to
Applicant Number	     	Contact	     
Customer Ref	     	Company	     
Contact	     	Street	     
E-Mail Address	     	City	     
Telephone	     	State	     
Fax	     	Zip	     
Faxed Certificate*		      Additional Certified Copies*

^{*additional charges apply}

I.1 Consignor Name       Address       Tel.Nº      

I.2 Certificate reference number      

1.2.a

I.3 Central Competent Authority AMS

I.4 Local competent Authority

I.5 Consignee Name       Address       Postal code       Tel.Nº      

I.6

I.7 Country of origin

ISO code

I.8 Region of origin

Code

I.9 Country of destination

ISO code

I.10

     

     

     

     

I.11 Place of origin

I.12

Name

Approval number      

     

Address

     

I.13 Place of loading      

I.14 Date of departure      

I.15 Means of transport

I.16 Entry BIP in EU

Aeroplane

Ship

Railway wagon

     

Road vehicle

Other

Identification:      

I.17

Documentation reference:      

I.18 Description of commodity

I.19 Commodity code (HS code)

     

     

I.20 Quantity (Net/Gross Weight)

     

I.21 Temperature of product

I.22 Number of packages

Ambient

Chilled

Frozen

     

I.23 Identification of container/Seal number

I.24 Type of packaging

     

     

I.25 Commodities certified for:

Human consumption

I.26 For transit through EU to 3rd country 3rd country       ISO code      

I.27 For import or admission into EU

I.28 Identification of the commodities

     

Species

Approval number of establishment

(Scientific name)

manufacturing plant

Number of packages

Net weight

Batch number

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

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 valid OMB control number for this information collection is 0581-NEW. The time required to complete this information collection is estimated to average 12 minutes/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.

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.