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.state.ks.us

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: