AES-08-03 - CERTIFIED SEED APPLICATION ADA

NOTES:

1) One variety per application.

2) Application must be signed by grower, appropriate fees attached and returned to Louisiana Department of Agriculture and Forestry at the above address by dates outlined in the Louisiana Seed Certification Standards.

3) The application must be filled out completely. Incomplete forms will not be processed.

APPLICATION FEE

Select one variety per application:

Sugarcane ($3.00 per acre)Turf Grass ($31.25 per acre)Sweet Potato ($2.25 per acre - Storage inspection is $25.00 per hour per inspector and mileage to and rom inspection location)Rice ($1.15 per acre)Other ($1.15 per acre for all other crops)

Number of Sugarcane Acres

Amount per Acre Sugarcane

Amount due Sugarcane

Number of Turfgrass Acres

Amount per Acre Turfgrass

Amount due Turfgrass

Number of Sweet Potato Acres

Amount per Acre Sweet Potato

Amount due Sweet Potato

Number of Rice Acres

Amount per Acre Rice

Amount due Rice

Number of Other Acres

Amount per Acre Other

Amount due Other

Is your application late? If yes, a $100 late fee will be applied.*

YesNo

Late Application Fee

Estimated Amount Due

A $25.00 per hour per inspector and mileage to and from will be charged for Sweet Potato crops. Fees based on hourly inspections and mileage will be invoiced by LDAF after inspections are performed.

Before processing this application, the following must be attached: 1) A tag and invoice showing origin and source of seed. 2) A detailed map(s) with GPS location of center of field, and landmarks, showing the exact location of each field. GPS coordinates must be listed in decimal degrees (DD) format. (Example - 29.83270600, -91.926661999)

Grower

Phone Number of Grower

Enter only numbers

Address of Grower

Street Address Line 2

CityState

Zip

Email

example@example.com

Parish (Farm Location)

Certifier

Phone Number of Certifier

Enter numbers only

Address of Certifier

Street Address Line 2

CityState

Zip

Email of Certifier

example@example.com

I am familiar with all the provisions of the regulations promulgated by the Louisiana Department of Agriculture and Forestry pertaining to certification of seed and do hereby agree to conform to and abide by all provisions set forth therein.

Contact Person

Telephone

Enter numbers only

Signature

Date

MonthDayYear

Crop

Variety

Before processing this application, the following MUST BE ATTACHED:

1. A tag and invoice showing origin and source of seed.

2. A detailed map(s) with GPS location of center of field, and landmarks, showing the EXACT location of each field. GPS Cordinates must be listed in decimal degrees (DD) format. (Ex. 29.832706000, -91.926661999)

Tag and Invoice Document Upload

Map Upload

CERTIFIED SEED APPLICATION

FIELD INFORMATION

FIELD 1

FIELD 2

FIELD 3

FIELD 4

FIELD 5