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EXPORT CERTIFICATE APPLICATION
(State Phytosanitary Certificate)
Nebraska Department of Agriculture, Animal and Plant Health Protection, Entomology Program
P.O. Box 94756, Lincoln, NE 68509-4756
Telephone: (402) 471-2351 Fax: (402) 471-6893
E-mail: agr.phyto@nebraska.gov Web Site: www.nda.nebraska.gov
Fill in application completely. Incorrect or incomplete applications may delay issuance. Submit application by fax or e-mail.
Please type or print clearly. Do not abbreviate anything. Original and copy of Export Certificate will be sent to only one
address. Original certificates cannot be faxed. If more room is needed in any of the boxes, include an attachment page.
2. Send completed certificate to: (If other than applicant.)
1.
Applicant name, address, and phone:
(Bill for export certificate will be sent to this address.)
3. Location of articles for inspection:
(Firm name, city, and state.)
4. Send completed certificate by:
Regular mail Will pick up at office Express mail (2 day)
Express mail (Overnight) Express mail (Saturday delivery)
Express mail company: UPS Fedex
Express mail account #:
5. State exported to:
6. Date of departure:
7.
Exporter name and address: (You or your broker’s info.)
8. Consignee name and address: (Destination info.)
10.
Quantity, common name and type of product:
Botanical name of product: (Scientific name)
Number and description of packages: (Include number of bags, railcars, containers, packets, boxes, etc.)
12.
Distinguishing marks: (Include container numbers, railcar numbers, truck or trailer license numbers, or markings on the bags or boxes.
For equipment certificates, include serial numbers. If there are no distinguishing marks, state “NONE”.)
Place of origin: (Indicate city or county and state.)
14. Means of conveyance: (How the product will arrive in the
export state. Indicate one of the following: railroad, ocean vessel,
truck line, air freight, or air mail.)
15. Point of entry: (Name of city or area where the shipment will
enter into the export state. If unknown, list state name.)
16. Import permit number: (If required)
Date Commodity Inspected: Name of Inspector:
Applicant Signature:__________________________________________ Date: _________________________
Phytosanitary certificates are issued every working day. We will try to issue and send out certificates for all complete applications received before
12:00 p.m. CST that same day. Complete applications received after 12:00 p.m. CST will be issued and sent the following business day. We DO
NOT guarantee same-day service. Certificates are not processed on weekends or state/federal holidays. No liability shall be attached to the
United States Department of Agriculture or the Nebraska Department of Agriculture or to any officer or representative of these departments with
respect to any phytosanitary applications or certificates.
Supporting documents being submitted with the application: (check all that apply)
Inspection Report Lab results from an Official Sample
Treatment Verification Form Growing Season Field Inspection Report
ENT91.doc (08/14)