Kentucky Office of the State Entomologist

Domestic Plant Inspection Application Form

Please fill out as completely as possible.

Remember to "TAB" or use your mouse to move between fields. If you hit "ENTER" you will submit your data and have to start over!
If you have any question, contact Carl Harper

Your current address:
(name, address, city, zip and phone number)
Line 1:
Line 2:
Line 3:
Line 4:
Line 5:
Line 6:

What state are you moving to?
Where will the articles be available for inspection:
When do you plan to move (date)?

List all plant material that you are considering taking with you:
Include the number of each type of plant, the common and/or botanical name. Separate each entry with a semi colon. Example: 3 - corn plants, Dracaena; 2 - croton, Codiaeum

What city do you live in?
What city are you moving to?
How are you moving your plants?:

Verification by telephone to (859) 257-5838 from you is required. This will allow us to make arrangements for the inspection. Currently, there is no charge for a domestic plant inspection and certificate issuance.

No financial liability shall attach to the Commonwealth of Kentucky or to any officer or representative of the Commonwealth with respect to this certificate.

Any intentional false statement in this domestic plant certificate or misrepresentation relative to this domestic plant certificate could result in the confiscation or destruction of the articles (at your cost) in the state you are moving to.

Name of Applicant:
Date: