Kentucky Office of the State Entomologist

State Phytosanitary Certificate Application Form

ONLY USE THIS FORM TO SUBMIT AN APPLICATION TO SHIP DOMESTICALLY (TO OTHER STATES AND U.S. TERRITORIES)!

If you are shipping internationally, | Click here | for information.

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

Exporter Address:
(name, address, city, zip and phone number)
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Line 5:
Line 6:

Applicant Address (if different from Exporter Address):
(name, address, city, zip and phone number)
Line 1:
Line 2:
Line 3:
Line 4:
Line 5:
Line 6:

Consignee Address
Line 1:
Line 2:
Line 3:
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Line 5:
Line 6:

Port of Export: Approx. Date of Departure:

Quantity & Name of Produce and Botanical Name:
Line 1:
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Line 5:

Number and Description of Packages:

Distinguishing Marks:
Line 1:
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Certified Origin:
Declared Point of Entry:
Declared Means of Conveyance:

Send completed Phytosanitary Certificate to:
(if different from Exporter Address or Applicant Address)
(name, address, city, zip and phone number)

Verification by telephone will be necessary before a Phytosanitary Certificate will be processed. If you have questions please contact Carl Harper and he will help you as best he can.

Name of Applicant:
Date: