Name of establishment or owner or custodian of seed: ........................................

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

A. PARTICULARS OF SEED SAMPLED:

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

    Mass of lot: ...........................................................

B. PARTICULARS ON CONTAINER OR LABEL:

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: ...........................................................