Fill out one application for each lot to be sampled. *Information is REQUIRED

Applicant Information (will appear on the certificate exactly as it is written here) *Name: Address: City: State: Zip: Contact Information (not to appear on OIC): Phone: Fax: Email: Check here if applicant should NOT appear on Orange certificate. Check if customer/billing is different from applicant. Billing name and address:
Seed Identification (will appear on the certificate exactly as it is written here) *Variety and Crop Species (write in order you want it to appear on certificate): *Lot No: *No. of containers: Type: *Lot Weight: * lb / kg *Crop Year (for germination, not incl. on OIC): Grower: Certification Class: *Treated or Coated Seed? NO YES with *PLEASE PROVIDE MSDS SHEET Other Info:
Sampling Information *Location of sampling (PLEASE INCLUDE ADDRESS AND CONTACT INFO): *Seed is prepared as described below, SET DOWN and ready for sampling: YES NO It is your responsibility to contact your warehouse and tell them sampling has been requested. Special instructions to sampler:
*ISTA Tests Needed Purity (P) Germination (G) Fluorescence (FL) Tetrazolium (TZ) Rush (add’l $109) Other Seed Determination (OSD) scope: Complete Reduced ( g) Limited: Moisture (M) Weight Det (1000wt) Australia origin of seed: __________ Other (specify):
ISTA Certificate Charges will apply for provisional and duplicate certificates (Original is included in testing price) Provisional (prelim) needed. Indicate the tests you want included on the provisional: Duplicate certificates: Quantity Special instructions for reporting on certificate:
Instructions Seed lot preparation prior to sampling: Seed lot must be a finished product as it is going to be in the final container. The lot must be properly identified and the amount quantified with total weight in lbs. or Kg. and number of bags. The lot can be piled up to 2 pallets high and all four sides of the pile must be accessible for sampling. If the lot is not SET DOWN AND READY for sampling, the sampler cannot sample and you may be charged a show-up fee. Send this form to the OSU Seed Lab. OSU Seed Lab Phone: 1-541-737-4464 3291 SW Campus Way Fax: 1-541-737-2126 Corvallis, OR 97331 Email: seedlab@oregonstate.edu
For Lab Use Only: Date Sampled: ______________ Date Rec’d at Lab: ____________ Lab Test #: _____________ Name of Sampler: _____________________________Sampler Lab Code (if not US07) __________ Seal & Bag intact: YES NO Seal of lot (circle): Stitched Lid Zip Tie _______________ Sampling OK? Checked by _______ & _______ Sample Entry checked by _______ & _______ Comments: