Above the bilingual table is the wordmark for the Canadian Food Inspection Agency. Following that is the title of the page, Receipt for Sample(s) Taken / Reçu pour échantillon(s) prélevés. Below these are the following messages:
The information is being used by the Canadian Food Inspection Agency to record non-payment for receipt of official samples. Some information may be accessible or protected as required under the provisions of the Access to Information Act.
Les renseignements sont utilisés par l'Agence canadienne d'inspection des aliments pour enregistrer la réception d'échantillons officiels non payés. Certains renseignements peuvent être accessibles ou protégés selon ce que prescrit la Loi sur l'accès à l'information.
The table has nine columns/fields:
The submitter then has 10 rows for samples. At the bottom left of the table is a field for the Multi Commodity Activities Program number, and to its immediate right is a field for the Inspector's signature. At the bottom of the Value column and to the left is written Total Value, indicating to the inputter a sum of all values should be put in the last and bottom field of the Value column.
Underneath the table is the call number of the form (Canadian Food Inspection Agency/Agence canadienne d'inspection des aliments 4168 (2000/08)), and then 1 - Owner / Propriétaire, 2 - Regional / Régionale, 3 - Inspector / Inspecteur and then the Canada wordmark.