Form ADA-EPSD255 "Application for Inspection and Certification of Plants and Plant Products for Domestic Export" - Arizona

What Is Form ADA-EPSD255?

This is a legal form that was released by the Arizona Department of Agriculture - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 8, 2021;
  • The latest edition provided by the Arizona Department of Agriculture;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form ADA-EPSD255 by clicking the link below or browse more documents and templates provided by the Arizona Department of Agriculture.

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Download Form ADA-EPSD255 "Application for Inspection and Certification of Plants and Plant Products for Domestic Export" - Arizona

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ARIZONA DEPARTMENT OF AGRICULTURE
ENVIRONMENTAL AND PLANT SERVICES DIVISION
APPLICATION FOR INSPECTION AND CERTIFICATION OF PLANTS AND PLANT PRODUCTS FOR DOMESTIC EXPORT
TO BE COMPLETED BY APPLICANT
CHECK ONE:
CERTIFICATE OF ORIGIN
STATE PHYTOSANITARY CERT.
EXPORTER NAME
APPLICANT NAME
ADDRESS
ADDRESS
CITY/STATE
CITY/STATE
ZIP
COUNTY
ZIP
PHONE
PHONE
FAX
E-MAIL
E-MAIL
Applicant responsible for payment of a phytosanitary certificate fee of $50.00 for the first lot plus $10 for each additional lot per site trip. Fees to be paid at time of
visit. Cash/Check Only. No fee for Certificate of Origin.
CONSIGNEE NAME
ADDRESS
CITY/STATE
ZIP
INSPECTION DATE/TIME REQ.
LOCATION WHERE ARTICLES WILL BE MADE AVAILABLE FOR
INSPECTION AND/OR TREATMENT AND CERTIFICATION
DESCRIPTION OF ARTICLES TO BE CERTIFIED
COMMON AND BOTANICAL
NAME, AND QUANTITY, OF
PLANT MATERIAL/PRODUCTS
NUMBER AND DESCRIPTION OF
CONTAINERS/PACKAGES
DISTINGUISHING MARKS
PLACE OF ORIGIN
DECLARED MEANS OF CONVEYANCE
I DECLARE, THAT THE PLACE WHERE
THE PLANT MATERIAL WAS GROWN
IS PROPERLY REPRESENTED.
AUTHORIZED SIGNATURE
DATE
EXPORT INSPECTION DATA - TO BE COMPLETED BY A DEPARTMENT INSPECTOR
% OF MATERIALS EXAMINED
LOCATION OF ARTICLES
% OF MATERIALS INFESTED
FINDINGS AND/OR TREATMENT AFFECTED (USE REVERSE IF NECESSARY)
DATE AND TIME INSPECTED
INSPECTOR'S SIGNATURE
https://agriculture.az.gov
ADA-EPSD 255 04/08/21 AD
ARIZONA DEPARTMENT OF AGRICULTURE - ENVIROMENTAL AND PLANT SERVICES DIVISION - 1688 W. ADAMS ST. - PHOENIX, AZ 85007 - (602) 542-0994 - F(602) 542-0922
ARIZONA DEPARTMENT OF AGRICULTURE
ENVIRONMENTAL AND PLANT SERVICES DIVISION
APPLICATION FOR INSPECTION AND CERTIFICATION OF PLANTS AND PLANT PRODUCTS FOR DOMESTIC EXPORT
TO BE COMPLETED BY APPLICANT
CHECK ONE:
CERTIFICATE OF ORIGIN
STATE PHYTOSANITARY CERT.
EXPORTER NAME
APPLICANT NAME
ADDRESS
ADDRESS
CITY/STATE
CITY/STATE
ZIP
COUNTY
ZIP
PHONE
PHONE
FAX
E-MAIL
E-MAIL
Applicant responsible for payment of a phytosanitary certificate fee of $50.00 for the first lot plus $10 for each additional lot per site trip. Fees to be paid at time of
visit. Cash/Check Only. No fee for Certificate of Origin.
CONSIGNEE NAME
ADDRESS
CITY/STATE
ZIP
INSPECTION DATE/TIME REQ.
LOCATION WHERE ARTICLES WILL BE MADE AVAILABLE FOR
INSPECTION AND/OR TREATMENT AND CERTIFICATION
DESCRIPTION OF ARTICLES TO BE CERTIFIED
COMMON AND BOTANICAL
NAME, AND QUANTITY, OF
PLANT MATERIAL/PRODUCTS
NUMBER AND DESCRIPTION OF
CONTAINERS/PACKAGES
DISTINGUISHING MARKS
PLACE OF ORIGIN
DECLARED MEANS OF CONVEYANCE
I DECLARE, THAT THE PLACE WHERE
THE PLANT MATERIAL WAS GROWN
IS PROPERLY REPRESENTED.
AUTHORIZED SIGNATURE
DATE
EXPORT INSPECTION DATA - TO BE COMPLETED BY A DEPARTMENT INSPECTOR
% OF MATERIALS EXAMINED
LOCATION OF ARTICLES
% OF MATERIALS INFESTED
FINDINGS AND/OR TREATMENT AFFECTED (USE REVERSE IF NECESSARY)
DATE AND TIME INSPECTED
INSPECTOR'S SIGNATURE
https://agriculture.az.gov
ADA-EPSD 255 04/08/21 AD
ARIZONA DEPARTMENT OF AGRICULTURE - ENVIROMENTAL AND PLANT SERVICES DIVISION - 1688 W. ADAMS ST. - PHOENIX, AZ 85007 - (602) 542-0994 - F(602) 542-0922