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REPRODUCE LOCALLY. Include form number and edition date on all reproductions. OMB No. 0581-0125

Exp. 10/31/2026

U.S. DEPARTMENT OF AGRICULTURE 

AGRICULTURAL MARKETING SERVICE 

APPLICATION FOR INSPECTION AND CERTIFICATE OF 

SAMPLING 

APPLICATION 

TAKEN BY (Initials) 

DATE HOUR 

NAME AND MAILING ADDRESS OF APPLICANT (Include City, State, ZIP) 

Enter your E-Mail Address here: 

NAME AND MAILING ADDRESS OF RECEIVER OR BUYER (Include City, State, ZIP) 

IF REQUESTED BY OTHER THAN APPLICANT, SPECIFY NAME OF PARTY CONTRACT OR ORDER NUMBER DATE AVAILABLE FOR SAMPLING/INSP. 

NOTE: Mark an “X” in appropriate blocks 

MAIL CERTIFICATE AND FEE BILL TO 

 APPLICANT  OTHER (Specify) 

DISTRIBUTION INSTRUCTIONS 

 FAX  USPS  OVERNIGHT  EXPRESS GROUND MAIL  OTHER 

TYPE OF PRODUCT  CANNED  FROZEN  DRIED  DEHYDRATED  OTHER 

NAME OF PRODUCT 

LOCATION OF PRODUCT (Name, Address, and Phone) 

TYPE OF CASE 

 NONE  DOMESTIC  OTHER (Specify) 

CASE MARKS (Specify in “Remarks” on reverse) 

 COMMERCIAL  SPECIAL

PRODUCT PREVIOUSLY GRADED 

 NO  YES (If “Yes”, give Certificate Number) 

FIELD OFFICE WHERE GRADED 

REPORT RESULTS IMMEDIATELY AFTER GRADING TO 

 APPLICANT  OTHER (Specify) 

QUALITY REQUIREMENTS OF RECEIVER 

ADDITIONAL REQUIREMENTS (Check all that apply) 

 Certificate of Date of Pack (Federal or State Agencies)  “Officially Sampled” stamp on cases. Stamp this form when accomplished

 Condition of Container Examination (Federal or State Agencies)

Attach Form AD-748 or 741

 Checkloading Required Date:_________________

 USDA Contracts–Country of Origin Certification and Traceability

Documents. (Plant Survey and Food Defense System Survey required) or 

Plant Systems Audit 

 Unofficial Sample Submitted by Applicant. See terms and signature

request on reverse side of this form

 SECTION 8e IMPORT PRODUCT INSPECTION:

Importer of Record Date of Arrival Port of Entry Name of Vessel/Voyage No. Customs Entry No. Bill of Lading No. 

Broker’s Reference No. FCE No. Port of Export Harmonized Tariff Code Container No. Country of Origin 

 EXPORT CERTIFICATE: 

Port of Export Port of Entry Name of Vessel. Voyage No. Date of 

Freezing 

Freezing 

Temp. °C. 

Storage 

Temp. °C. 

 OTHER: PLEASE SPECIFY IN REMARKS 

LOT NO. LOT SIZE AND 

DESCRIPTION 

NO. AND TYPE OF 

CONTAINERS IN CASE  EMBOSSED

CODE MARKS IN LOT 

 INK STAMPED  INK JET OTHER 

NO. SAMPLES

ADDITIONAL SAMPLE UNITS FOR:  ANALYTICAL  USDA REVIEW  MONTHLY REVIEW  OTHER 

REMARKS: 

THIS IS TO CERTIFY that in compliance with the regulations of the Secretary of Agriculture governing the inspection of processed fruits and vegetables pursuant to the Agricultural 

Marketing Act of 1946, as amended, I have this day drawn samples believed by me to be representative of the lots described above. 

DATE ADDRESS OF SAMPLER OR FIELD OFFICE OFFICIAL SAMPLER PRINT AND SIGN NAME 

DATE DRIVING 

(HRS) 

SAMPLING 

(HRS) 

STAMPING 

(HRS) 

CONDITION 

(HRS) 

CHECKLOADING 

(HRS) 

PRODUCT 

EXAM (HRS) 

OTHER 

(HRS) 

TOTAL 

HOURS 

OVERTIME 

(HRS) 

NIGHT 

DIFF (HRS) 

INSP 

INT. 

(OVER) 

SC-356 (1-2024) Previous editions are to be destroyed. USDA is an equal opportunity provider, employer, and lender. Page 1 of 2 
 

 

 

 

 

 

 

 

 

 

 

CERTIFICATE OF SAMPLING 

THIS IS TO CERTIFY that in compliance with the regulations of the Secretary of Agriculture governing the inspection of processed fruits and vegetables pursuant to the 

Agricultural Marketing Act of 1946, as amended, I have this day drawn samples believed by me to be representative of the lots described below. 

CONTRACT NUMBER PURCHASE ORDER NUMBER 

NAME AND MAILING ADDRESS OF APPLICANT (Include City, State, Zip) NAME AND LOCATION OF WAREHOUSE (Include City and State) 

PRODUCT SIZE AND KIND OF CONTAINERS 

TYPE OF CASE (if cased)  CORRUGATED  OTHER  Tray Pack NUMBER PER CASE 

CASE MARKINGS (if any) 

LOT NO. NO. SAMPLES EMBOSSED 

CODE MARKS 

INK STAMPED INK JET OTHER NO. CASES LOCATION IN 

WAREHOUSE 

REMARKS 

DATE OFFICIAL SAMPLER PRINT AND SIGN NAME ADDRESS OF FIELD OFFICE/INSPECTION POINT 

The undersigned applies for inspection of the processed food products described in this application in accordance with the regulations of the Secretary of Agriculture (7 CFR). To the best of my knowledge 

and belief, these containers are not from lots which have been previously inspected by the U.S. Department of Agriculture and are in no way the subject of controversy with any government agency. 

NAME AND TITLE OF REQUESTOR SIGNATURE OF REQUESTOR 

Information in this application will be used in connection with performing an inspection on the product described in this application (7CFR 52). According to the Paperwork Reduction Act of 1995, an agency 

may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection 

is 0581-0125. The time required to complete this information collection is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering 

and maintaining the data needed, and completing and reviewing the collection of information. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis 

of race, color, national origin, gender, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because 

all or part of an individual’s income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of 

program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD).To file a complaint of discrimination, write to USDA, Director, Office of 

Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer. 

SC-356 (1-2024) Previous editions are to be destroyed. USDA is an equal opportunity provider, employer, and lender. Page 2 of 2