DA-247 Sanitary Certificate Request - Peru

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

SANITARY CERTIFICATE REQUEST

TYPE

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 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.

Faxed Certificate

PeTu

0 Additional

Copies'

'additional charses applv

that by checking this box that the information provided

1. CONTACT NAME

is factual and accurate.
MAILING INFORMATION
7. COMPANY

2. AMS BILLING ACCT.

8. CONTACT

3. BILLING REFERENCE

9. STREET

4. E-MAIL

10. CITY

I acknowledge

CONTACT INFORMATION

ADDRESS

5. CONTACT PHONE

11. STATE

6. FAX

12.ZtP

CONSIGNOR

13. NAME
14. ADDRESS

1s. c|rY/STATE
CONSIGNEE

16. NAME
17. ADDRESS
18. COUNTRY CODE

PE

IDENTIFICATION OF DAIRY PRODUCTS
].9. DESCRIPTION OF COMMODITY
20. PRODUCT IDENTIFICATION
21. WPE OF PACKAGING

22.
23.
24.
25.

NUMBER OF PACKAGING UNITS
tb

NET WEIGHT
PASTEURIZED?
I

YES

NDIVIDUALLY PACKED?

YES

26. SENASA PERMIT NO.
MANUFACTURER

27. PLANT NUMBER
SIGNATURE (for faxed or moiled copies)

28. DATE

**Forfastest processing, please attachthisform and a PDFshipping labelin an emailto DairvSanitaryCerts@ams.usda.sov.
DA-247 lOLl2Or6l

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

rnay be rnade available in larguages other than English

94

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(2) tax: (202]. 690-1 442; or

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USDA is an equal opportunity provider, employer, and lender