Date:	Sample At:
OSU Seed Lab	Address:
3291 SW Campus Way	City
Corvallis, OR 97331	Phone
541-737-4464 / 541-737-2126 fax	Contact
Contact: Jodi Keeling	Sampler Info
Sample according to ISTA Rules and complete declaration.

OSU Seed Lab ISTA Sampling

Client:

Sampling Location:

Customer’s Information

Variety & Crop:

Lot No:

No. Containers:	Lot Weight:

Kg Lb

Tests Requested:

Purity	Other Seed Determ.

Germination	Fluorescence

TZ	Moisture

Weight Det (1000wt)	Australia

Other:

Treated/Coated With:

(INCLUDE MSDS SHEET)

Other Info:

OSU Seed Lab ISTA Sampling

Client:

Sampling Location:

Customer’s Information

Variety & Crop:

Lot No:

No. Containers:	Lot Weight:

Kg Lb

Tests Requested:

Purity	Other Seed Determ.

Germination	Fluorescence

TZ	Moisture

Weight Det (1000wt)	Australia

Other:

Treated/Coated With:

(INCLUDE MSDS SHEET)

Other Info:

ISTA Sampler Declaration

Is the lot uniquely and adequately marked? YES NO

Size of Containers: 25Kg 25lb 50lb 55lb _______

Total lot size____________________Kg or lb

Type of Container: Poly Sack, Paper Sack, Bucket,

Tri-wall, Other: _______ Number of Containers: _______

Method/Probe: Nobbe Sleaved Hand

Number of Primary Samples Taken: ____________

Lot sealed by: Stitching, Lid, Tag, Heatseal, _______

Were the primary samples uniform? YES NO

Is Seed Treated/Coated: NO YES, With___________

Printed Name of Sampler: ___________________________________________

Signature of Sampler: ___________________________________________

Date of Sampling: ____________________________

I hereby declare, by signature or initial on sample container, that the lot was sampled according to ISTA rules and procedures and is representative of the seed lot.	ISTA Sampler Declaration

Is the lot uniquely and adequately marked? YES NO

Size of Containers: 25Kg 25lb 50lb 55lb _______

Total lot size____________________Kg or lb

Type of Container: Poly Sack, Paper Sack, Bucket,

Tri-wall, Other: _______ Number of Containers: _______

Method/Probe: Nobbe Sleaved Hand

Number of Primary Samples Taken: ____________

Lot sealed by: Stitching, Lid, Tag, Heatseal, _______

Were the primary samples uniform? YES NO

Is Seed Treated/Coated: NO YES, With___________

Printed Name of Sampler: ___________________________________________

Signature of Sampler: ___________________________________________

Date of Sampling: ____________________________

I hereby declare, by signature or initial on sample container, that the lot was sampled according to ISTA rules and procedures and is representative of the seed lot.

OSU Seed Lab

ISTA Sampling Request and Declaration

WI-218c.5 ISTA Sampling Request and Declaration	Approved 02/08/16 by J. Keeling	Pg 1 of 1

To be filled by Customer or OSU Seed Lab

To be filled by Customer or OSU Seed Lab

To be filled by ISTA sampler

To be filled by ISTA sampler

Name of Training

Kim Armstrong

2016-02-09

Jodi Keeling

Seed Certification