Sanitary Certificate Request - Peru

Form Approved OMB No. 0581-NEW

U. S DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE SANITARY CERTIFICATE REQUEST-PERU				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 18 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. PRODUCT IDENTIFICATION					     
17. DESCRIPTION OF COMMODITY					     
18. NET WEIGHT					     
19. TYPE OF PACKAGING					     
20. NUMBER OF PACKAGING UNITS					0
MANUFACTURER
21. PLANT NUMBER			     ;      ;      
PLACE OF LOADING
22. CITY, STATE			     
DESTINATION
23. NAME OF RECEIVER			     
24. CITY			     
25. SENASA IMPORT PERMIT NO.			     
26. SIGNATURE OF AGENT FOR APPLICANT						27. DATE
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