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

B: NAME OF ESTABLISHMENT OR OWNER OR CUSTODIAN OF SEED:

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

C. REFERENCE NUMBER OF TEST, EXAMINATION OR ANALYSIS:

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

D. *PARTICULARS OF SEED IN RESPECT OF KIND, VARIETY, POLLINATOR:

Kind of seed: .....................................................................

Variety: .............................................................................

Percentage pollinator: .......................................................

E. PARTICULARS OF PHYSICAL PURITY:

1. Percentage pure seed (or in the case of coated seed, percentage pure units of coated  seed):

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

2. Percentage other seed:

2.1        Percentage other crop seed: ........................................

 Specify: .............................................................................

2.2        Percentage weed seed: ................................................

 Specify: ..............................................................................

 Total (2.1 + 2.2): ..................................................................

3. Percentage inert matter: ......................................................

4. Percentage other material (Total of 2 and 3): ........................

5. Number of prohibited weed seeds per mass: .......................

F(1). * PARTICULARS OF GERMINATION OF SEED:

Percentage normally germinated: ......................................

Percentage hard seeds: ......................................................

Percentage of healthy seeds not germinated: .....................

Percentage mouldy seeds: ..................................................

Percentage abnormal seeds: ...............................................

Other (specify): ...................................................................

F(2).  PARTICULARS OF VIABILITY OF SEED:

Percentage viable: ................................................................

Percentage negatively stained: .............................................

Percentage unstained: ..........................................................

G.  PARTICULARS OF PLANTS:

Percentage of kind: ...............................................................

Percentage of variety: ...........................................................

Percentage of deviation: ........................................................

Percentage hybrid plants: ......................................................

Percentage pollinator plants: .................................................

Description of deviations: ......................................................

H.  PARTICULARS OF OTHER ANALYSIS: .........................................

Name of officer who did analysis: ...............................................

I hereby declare that—