Name of establishment or owner or custodian of plants and propagating material: .............................

Address where sample was taken: ................................................

A. PARTICULARS OF PLANTS AND PROPAGATING MATERIAL SAMPLED:

    Number of containers: ..............................................................

    Number of plants or propagating material: ................................

     Sealing: ....................................................................................

B. PARTICULARS ON CONTAINER OR LABEL:

* Kind of plant: .............................................................................

* Variety .......................................................................................

  If grafted:

  Certificate number (if certified): .................................................

C. IDENTIFICATION MARK ON LABEL OF SAMPLE: .............................

D. NAME AND ADDRESS OF SUPPLIER (IF INDICATED ON CONTAINER OR LABEL ATTACHED TO CONTAINER):

........................................................................................................

Name of officer taking sample: ........................................................

Name of witness at sampling: ..........................................................

I hereby declare that the methods for the taking of a sample as determined by the Registrar of Plant Improvement, have today been complied with by me when I took the sample of the seed indicated above.

Signature of officer: .........................................................................

Date: ................................................................................................

Place:  ..............................................................................................

Signature of witness: ........................................................................

Remarks by officer: ...........................................................................