DA-240 Sanitary Certificate Request

Form Approved OMB No. 0581-0283
U. S DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE SANITARY CERTIFICATE REQUEST			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.
TYPE		Faxed Certificate*		0 Additional Copies*	*additional charges apply
I acknowledge that by checking this box that the information provided is factual and accurate.
CONTACT INFORMATION				MAILING INFORMATION
1. CONTACT NAME		     		7. COMPANY	     
2. AMS BILLING ACCT.		     		8. CONTACT	     
3. BILLING REFERENCE		     		9. STREET	     
4. E-MAIL ADDRESS		     		10. CITY	     
5. CONTACT PHONE		     		11. STATE	     
6. FAX		     		12. ZIP	     
CONSIGNOR
13. NAME		     
14. ADDRESS		     
15. CITY/STATE		     
CONSIGNEE
16. NAME		     
17. ADDRESS		     
18. COUNTRY CODE		  
IDENTIFICATION OF DAIRY PRODUCTS
19. DESCRIPTION OF COMMODITY				     
20. KIND OF HEAT TREATMENT (HTST; PASTEURIZED) 				     
21. TYPE OF PACKAGING 				     
22. NUMBER OF PACKAGING UNITS				     
23. NET WEIGHT				     
24. REQUIRED TEMPERATURE DURING STORAGE AND TRANSPORTATION				     
25. EXPIRATION DATE				     
MANUFACTURER
26. PLANT NUMBER		     		     	     
SHIPMENT INFORMATION
27. DEPARTURE PORT		     
28. TRANSPORT TYPE 		     
SIGNATURE (for faxed or mailed copies)				29. DATE January 16, 2021

**For fastest processing, please attach this form and a PDF shipping label in an email to DairySanitaryCerts@ams.usda.gov.

DA-240 (01/2013)

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD).

To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.