Declaration of Sampler Report FOR APHIS / EXPORTOrigin* Kind of Seed* Scientific Name* Variety* Lot NO.* Size of Lot Being Exported* Crop Certificate NO. Sampling Equipment Used* NO. of Samples Taken* Sample Seed & Treatment* Sample Taken At* Conditioned / Packaged By* Declaration* I hereby declare that I have sampled the above lot according to recognized standard sampling procedures and this sample truly represents the seed lot. Name of Sampler* First Last Grader / Sampler License NO.* Date* MM slash DD slash YYYY