Sanitary Certificate Request - Algeria

Form Approved OMB No. 0581-NEW

U. S DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE SANITARY CERTIFICATE REQUEST-ALGERIA

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-NEW. 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.

I acknowledge that by checking this box that the information provided is factual and accurate.

CONTACT NAME

     

MAIL CERTIFICATE TO:

CUSTOMER NUMBER

     

7. COMPANY

     

BILLING REFERENCE

     

8. CONTACT

     

E-MAIL ADDRESS

     

9. STREET

     

CONTACT PHONE

     

10. CITY

     

FAX

     

11. STATE

     

12. ZIP

     

IDENTIFICATION OF DAIRY PRODUCTS

13. DESCRIPTION OF COMMODITY

     

14. NUMBER OF PACKAGING UNITS

0

15. NET WEIGHT

     

16. GROSS WEIGHT

     

17. LOT NUMBER

     

18. LOT CODE

19. QUANITY (BAGS/CARTONS)

20. NET WEIGHT

21. PRODUCTION DATE

22. EXPIRY DATE

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

MANUFACTURER

23. PLANT NUMBER

     ;      ;      

24. DATE OF PRODUCTION

     

ORIGIN

COUNTRY OF ORIGIN

UNITED STATES OF AMERICA

EXPORTER

25. NAME

     

26. ADDRESS

     

PRODUCER

27. NAME

     

28. ADDRESS

     

DESTINATION OF GOODS

29. PLACE OF LOADING; CITY, STATE

     

30. DESTINATION CITY

     

IMPORTER

31. NAME

     

32. ADDRESS

     

33. SHIP NAMEAND VOYAGE NUMBER

     

34. SIGNATURE OF AGENT FOR APPLICANT

35. DATE

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.