Hay Examination Report

This is a Hay Examination Report.  The following is the information is requested:

Number

Hay Location (Legal Description - use back if necessary)

Grower's Name and Address (and, if applicable, non-designated facility name and address)

Name of Company Requesting Examination

Country of Destination

Hay For Examination (Mixture %, Lot)

Bale Type

Total Number of Bales

Weight Per Bale

Total Weight

Foreign Material

Prohibited Material

Identify Lots Rejected

Number of Bales Passed x Weight Per Bale= Total Weight (metric tonnes)

Examined By:

(Print Name of Examiner)

Date

Number of phytosanitary certificate

Metric Tonnes

Balance

Date Examined

Signature