- 12A - 
PLANT PROTECTION SERVICE 
OF No. 
This is to certify- 
that the plants, parts of plants or plant products described below have 
been thoroughly examined, completely or a representative sample, on 
(date) by (Name) • • « 
an authorized officer of (Service) •• 
and are found to the best of his knowledge to be substantially free from 
injurious insects and pests, and that the shipment (consignment) is 
believed to conform with the current phyto sanitary regulations of the 
importing country both as stated in the additional declaration hereon and 
otherwise. 
Fumigation or disinfection (if required by the importing country): 
Date Treatment .... 
Duration of treatment c Chemicals used and concentrations . . 
Additional declaration: The examination made on the representative sample 
represents a percentage of of the shipment (consignment), has 
shown (revealed) that the commodity thus looked at was free from San Jose 
Scale ( Quadraspidiotus perniciosus Comsto) 
Done at. ...... « the 19 • 
. t (Signature) 
Seal of Service , (Title) ' 
DESCRIPTION OF CONSIGNMENT 
Name, First name and address of exporter ........... 
Name, First name and address of consignee • • 
Name and description of packages , , . , „ .,.,....„ . ..... . t 
Distinguishing marks of packages ..., o 
Origin (if required by importing country) e . . . . 
Means of conveyance •««••«.*••••. 
Port of entry. ... = .. 
Quantity and name of produce . • »•*.»•* 
Botanical name (if required by importing country) 
