DA-243 Sanitary Certificate Request - Brazil

Form Approved OMB No.0581-0283
U. S DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

SANITARY CERTIFICATE REqUEST

TypE

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 0581-0283. 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.
radditional charges applv

raxed certificate0 Additional copiesI acknowledse that bv checking this box that the information provided is factual and accurate.

I-l

1. CONTACT NAME

MAILING INFORMATION
7. COMPANY

2. AMS BILLING ACCT.

8. CONTACT

3. BILLING REFERENCE

9. STREET

4. E-MAIL

10. crTY

CONTACT INFORMATION

ADDRESS

5. CONTACT PHONE

11. STATE

6. FAX

12.ZtP

CONSIGNOR

13. NAME
14. ADDRESS
15. CITY/STATE
CONSIGNEE

16. NAME
17. ADDRESS
18. COUNTRY CODE

BR

IDENTIFICATION OF DAIRY PRODUCTS

19. DESCRIPTION OF COMMODITY
20. LOT NUMBER

2].. NUMBER OF PACKAGING UNITS
22. NET WEIGHT
23. IDENTIFICATION MARKS

tb

24. DATE PRODUCED
MANUFACTURER

25. PLANT NUMBER
SHIPMENT INFORMAT!ON

26. DEPARTURE PORT

27. ENTRY PORT
28. DATE

SIGNATURE (for foxed or moiled copies)

**Forfastest processing, please attach thisform and a

PDF

shipping labelin an emailto DairvSanitaryCerts@ams.usda.eov.

DA-243 (OLl2Ot6l

InaccordancewithFederal civil rightslawandUS DepartmentofAgriculture(USDA)civil rightsregulationsandpolicies,theUSDA,itsAgencies,offices,and
employees, and instirtions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender
beliefs, or reprisal or retaliation for prior civit 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.9., 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, lound online at
http://www.ascr usda.gov/complaint_filing_cust html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested
in the form. To request a copy of the complaint form, call (866) 632-9992 Submit your complete d form or letter to USDA by: ( I ) mail: U.S. Department of Agriculture

OfficeoftheAssistantSecretarylorCivil Rightsl400 lndependenceAvenue,SWWashington,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.