Form 89-814 Request for inspection services

OMB Control #0648-0266
Expires: 08-2018

NOAA form 89-814

U.S. DEPARTMENT OF COMMERCE

Prescribed by NOAA Inspection Manual 25

CONTRACT NUMBER:

NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION

FEDERAL TAX ID #:

XXXXXXXXXXXXXXXXXXXXXX

REQUEST FOR INSPECTION SERVICES

TODAY’S DATE:

NAME OF REQUESTER

SERVICING AGENT’S NAME & PHONE NUMBER

STREET ADDRESS

STREET ADDRESS

CITY

STATE

CONTACT NAME

PHONE NO.

ZIP CODE

FAX NO.

CITY

STATE

ZIP CODE

TYPE INSPECTION REQUESTED

___ Lot Inspection Certificate
___ Export Health Certificate
___ Certificate of Origin
___ EU Certificate
___ Other:

LOCATION OF PRODUCTS – NAME

LOCATION OF PRODUCTS – STREET ADDRESS
CITY

SPECIAL INSTRUCTIONS (Buyer Specifications, country
requirements, etc.)
STATE

ZIP CODE

___ Market Specifications:
___ Product on FDA Hold?
DISPOSITION OF SAMPLES:

ASSESS CHARGES TO:

___ Return
STREET ADDRESS

___ Destroy

___ Charity

INSPECT FOR:

Same
CITY

STATE

ZIP CODE

STATE

ZIP CODE

CERTIFICATE FORWARDED TO:
STREET ADDRESS

___ Quality & Condition
___ Minimum U.S. Grade Attributes
___ U.S. Grade A Attributes
___ Net Weight
___ Size or Count
___ Other:
Origin:

Same
CITY
REMARKS

LOT NUMBER

BRAND

PRODUCT

NUMBER OF CARTONS/
CASES & SIZE

NAME OF SHIPPER (For export only)

NAME OF CONSIGNEE (For export only)

ADDRESS

ADDRESS

PORT OF EXPORT

VESSEL OR AIRLINE

APPLICANT (Printed Name & Signature)

TOTAL POUNDS

PORT OF DESTINATION
DATE

Information Collection Notification – NOAA Form 89-814
This information collection is authorized under 50 CFR §260.15. The information will be used to record applicants requesting inspection services on non-contractual basis.
Public reporting burden for this collection of information is estimated to average 5 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 of information. Send comments regarding this burden estimate or any other
aspect of the collection of information, including suggestions for reducing this burden to the Seafood Inspection Program, 1315 East-West Highway, Silver Spring, MD 20910.
This information is required in order to receive inspection services on non-contract basis. Notwithstanding any other provision of the law, no person is required to respond to,
nor shall any person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act, unless that
collection of information displays a currently valid OMB control Number.