<p> REQUEST FOR EXPORT SANITARY CERTIFICATE</p><p>Email request to [email protected] or fax to: 360-902-2087. If you have questions please contact us at 360-902-1876.</p><p>Contact Contact Name: Number: Email: Date Submitted:</p><p>Number of Originals Requested: ($75 per Original)</p><p>Country Shipping To:</p><p>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</p><p>Additional Notes or Specific Requests: Product Information to Appear on Certificate (attach additional information if necessary): Processsing Plant Name: Physical Address: City, State, Zip</p><p>Billing address same as certificate mailing address. </p><p>Mail Certificate To*: Billing Address: Company: Company: Contact Contact Name: Name: Email: Email: Address: Address: City, State, City, State, Zip: Zip:</p><p>AGR FORM 601-2089E (R/9/15) *Note: FedEx will not deliver to a PO Box.</p><p>Federal Express billing number:</p><p>FOR OFFICE USE ONLY: Date Received: License # Inspector: Last Inspection Date: L UL</p><p>Score: Account 90 Days Overdue Invoice # </p><p>4101</p><p>AGR FORM 601-2089E (R/9/15)</p>