If You Have Questions Please Contact Us at 360-902-1876
Total Page：16
File Type：pdf, Size：1020Kb
REQUEST FOR EXPORT SANITARY CERTIFICATE
Email request to [email protected] or fax to: 360-902-2087. If you have questions please contact us at 360-902-1876.
Contact Contact Name: Number: Email: Date Submitted:
Number of Originals Requested: ($75 per Original)
Country Shipping To:
Type of Certificate Requested: (Examples on website. See WSDA Food Safety Export Certificates ) Public Health & Sanitary Certificate – Example 1 Sanitary Certificate – Example 2 Certificate of Sanitation and Free Sale – Example 3 Certificate of Sanitation – Example 4 Certificate of Free Sale (Dietary & Nutritional Supplements) – Example 5
Additional Notes or Specific Requests: Product Information to Appear on Certificate (attach additional information if necessary): Processsing Plant Name: Physical Address: City, State, Zip
Billing address same as certificate mailing address.
Mail Certificate To*: Billing Address: Company: Company: Contact Contact Name: Name: Email: Email: Address: Address: City, State, City, State, Zip: Zip:
AGR FORM 601-2089E (R/9/15) *Note: FedEx will not deliver to a PO Box.
Federal Express billing number:
FOR OFFICE USE ONLY: Date Received: License # Inspector: Last Inspection Date: L UL
Score: Account 90 Days Overdue Invoice #
4101
AGR FORM 601-2089E (R/9/15)