FORM OF CERTIFICATE. 



* International Phylloxera Convention of Berne and 



International Phytopathological Convention of Eome. 



Certificate for cormgnmevts of liorticuUural plants. {Each statement on the 



Certificate to be accoinpanied by a translation in French.) 



Name of Exporting Country. 



I. — Declaration of the Exporter. 



The undersigned (1) 



declares : — 



A. That the plants (2) 



contained in (3) packages, marked (4) 



addressed to (5) 



i,-^ (6) have been produced entirely fiom 



his establishment or from other establishments under inspection by the 

 Phytopathological service ; 



*B. That this consignment contains no vines ; 



*C. That the plants are packed (7) 



earth. 



(8) the day of 19 



Consignment from (9) 



* Establishments entered in the list 

 compiled in conformity with Article 9, §6 

 of the Eerne Convention on Phylloxera, 

 under the 



No (10) 



•j-II. — Attestation of the Administrative Authority. ^ 

 The administiative authority attests : — 



A. That the above consignment of plants comes from ground 

 separated from any vine plant by a space of at least 20 metres, 



(1) Name, firm, profession and address ; (2) Kinds and quantity of plants ; (3) Number of 

 packages ; (4) Mark and number ; (5) Complete address of the consignee, name, profession, 

 domicile ; (6) Name of the importing country ; (7) Mention if the plants are packed tvith 

 or withoid earth ; (8) Place of departure ; (9) Signature of the exporter ; (10) Enter the 

 number under which the establishment is entered in the general list. 



*Only required for States adhering to the Berne Convention. 



fThis certificate is only required for countries adhering to the Berne Convention and then 

 only in case the establishment does not figure on the list published in virtue of Article 9, § 6 of 

 the Berne Convention. 



' Burgomaster, Mayor, or other competent authority according to the country. 



