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Export Certificate Application

Plant Protection and Weed Control Section
Forbes Field - Building 282, P.O. Box 19282
Topeka, KS 66619-0282
Telephone: (785) 862-2180 Fax: (785) 862-2182
ppwc@kda.ks.gov

Instructions

*Applicant Name:

*Address:

*Telephone:

Fax:

Mail Shipper Copy To (if different from APPLICANT)

Name:

Address:

Exporter Information: (if different from APPLICANT)

Name:

Address:

Consignee Information (Must be in the Destination Country/State)

*Name:

*Address:

*Destination Country or State:

*Common Name of Commodity:

*Quantity of Commodity:

*Location of Commodity:

Botanical Name of Commodity:

*Origin of Commodity:

Inspection Date:

*Number and Description of Package:

*Distinguishing Marks or Identification:

*Means of Conveyance:

Point of Entry:

*Date the inspection needed to be completed by:

If you wish to have the original certificate returned by express delivery, please complete the following:

Express Company:

Express Deliver To:

Account Number:

Kansas Department of Agriculture

Export Certificate Application

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