Sanitary Certificate Request - Brazil

Form Approved OMB No. 0581-NEW

U. S DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE SANITARY CERTIFICATE REQUEST-BRAZIL				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	     
EXPORTER
13. NAME	     
14. ADDRESS	     
15. CITY, STATE	     
IDENTIFICATION OF DAIRY PRODUCTS
16. DESCRIPTION OF COMMODITY					     
17. DATE OR PERIOD OF PRODUCTION					     
18. LOT NUMBER					     
19. NUMBER OF PACKAGING UNITS					0
20. NET WEIGHT					     
21. IDENTIFICATION MARKS					     
MANUFACTURER
22. PLANT NUMBER			     ;      ;      
DESTINATION
23. EXPORTER NAME			     
24. EXPORTER ADDRESS			     
25. NAME OF RECEIVER			     
26. CONSIGNEE ADDRESS			     
27. PLACE OF LOADING			     
28. PLACE OF DESTINATION			     
29. SIGNATURE OF AGENT FOR APPLICANT						30. 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.