DA-240 Sanitary Certificate Request

Form
U S DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

SANITARY CERTIFICATE REQUEST

OMB No.0581-0283

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 0581-0283, 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.

axedcertificate.0AdditionalCopies-+additionalchargesapp|y
that by checking this box that the information provided

CONTACT INFORMATION
1. CONTACT NAME

is factual and accurate.
MAITING INFORMATION
7. COMPANY

2. AMS BILLING ACCT.

8. CONTACT

3. BILLING REFERENCE

9. STREET

4. E-MAIL

10. crTY

I acknowledge

ADDRESS

5. CONTACT PHONE

11. STATE

6. FAX

12.ZtP

CONSIGNOR

13. NAME
14. ADDRESS

1s. C|TY/STATE
CONSIGNEE

16. NAME
17. ADDRESS
18. COUNTRY CODE
!DENTIFICATION OF DAIRY PRODUCTS

19. DESCRIPTION OF COMMODITY
20. KIND OF HEATTREATMENT (HTST; PASTEURIZED)
21. TYPE OF PACKAGING

22. NUMBER OF PACKAGING UNITS
23. NET WEIGHT
24. REQUIRED TEMPERATURE DURING STORAGE AND

tb

TRANSPORTATION

25. EXPIRATION DATE
MANUFACTURER

26. PLANT NUMBER
SHIPMENT lNFORMATION

27. DEPARTURE PORT
28. TRANSPORT TYPE
SIGNATURE (for foxed or moiled copies)

29. DATE

**Forfastest processing, please attach this form and a PDF shipping label in an emailto DairvSanitarvCerts@ams.usda.eov.
DA-240 (01/2016)

InaccordancewithFederal civilrightslawandU.S DepartmentofAgriculture(USDA)civil rightsregulationsandpolicies,theUSDA,itsAgencies,offices,and

beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs) Remedies and
complaint filing deadlines vary by program or incident
Persons with disabilities who require altemative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.)
should contact the responsible Agency or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 8778339 Additionally, program information may be made available in languages other than English

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at
http:i/www ascr usda.gov/complaint-filing-cust.html and at any USDA olTice or write a letter addressed to USDA and provide in the letter all of the information requested

intheform Torequestacopyofthecomplaintform.call (866)632-9992.SubmityourcompletedformorlettertoUSDAby: (l)mail: U.s.DepartmentofAgriculture
Office of the Assistant Secretary for Civil Rights 1400 lndependence Avenue, SW Washington,D.C 20250-9410; (2) fax: (202) 690-7442;or (3) email:
program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender,