ACCREDITATION APPLICATION FORM - NSHSseedhealth.org/wp-content/uploads/2017/04/NSHS-New... · Plant Health Programs – Export Services E-mail: [email protected] 4700 River

VERSION 3.2

MARCH 29, 2017

TABLE OF CONTENTS

APPLICANT DETAILS . . . . . . . . . . 2

ACCREDITATION OPTIONS . . . . . 3

TESTING SITE LOCATIONS . . . . . . 3 - 6

OPTION 1 . . . . . . . . . . . . . . . . . . . 7

OPTION 2 . . . . . . . . . . . . . . . . . . . 8 - 12

OPTION 3 . . . . . . . . . . . . . . . . . . . 13

OPTION 4 . . . . . . . . . . . . . . . . . . . 14

APPLICATION SUBMISSION . . . . . 15

ACCREDITATION APPLICATION FORM

Page 2 of 15

APPLICANT DETAILS

COMPANY/ORGANIZATION TO BE ACCREDITED

Legal Name Click or tap here to enter text

Street Address

City State Zip Code

Telephone Number Fax Number

E-mail Address

Website URL

CONTACT PERSON

Full Name Click or tap here to enter text

Posi�on

Street Address

City State Zip Code

Telephone Number Fax Number

E-mail Address

TYPE OF COMPANY/ORGANIZATION

☐ Seed Company

☐ Private Seed Company

☐ Private Agricultural Consultants

☐ Cer�fica�on Agency

☐ State/County Agency

☐ University Laboratory

☐ Other

Page 3 of 15

ACCCREDITATION OPTIONS

SITE DEFINITIONS

TEST SITE LOCATIONS TO BE ACCREDITED

SITE LOCATION 1

Site Loca�on Name (State) Click or tap here to enter text

Street Address

City State Zip Code

Contact Person Posi�on

Telephone Number

E-mail Address

Accredita�on ☐ OPTION 1 ☐ OPTION 2 ☐ OPTION 3 ☐ OPTION 4

• Laboratory-based program to test for plant pathogens in seeds.

OPTION 1: Seed Health Testing

• Disease Inspection of plants grown to produce seed in the field, nursery, orgreenhouse.

OPTION 2: Phytosanitary Inspection

• Sampling seeds that require laboratory seed health tests.

OPTION 3: Seed Sampling for Seed Health Testing

• Visual inspection of seed shipments at exporter's facility prior to issuance ofphytosanitary certificates.

OPTION 4: Visual Inspection of Seed for Phytosanitary Certification

Page 4 of 15

TEST SITE LOCATIONS TO BE ACCREDITED (CONTINUED)

SITE LOCATION 2


Street Address

City State Zip Code


Telephone Number

E-mail Address


SITE LOCATION 3


Street Address

City State Zip Code


Telephone Number

E-mail Address


SITE LOCATION 4


Street Address

City State Zip Code


Telephone Number

E-mail Address


Page 5 of 15


SITE LOCATION 5


Street Address

City State Zip Code


Telephone Number

E-mail Address


SITE LOCATION 6


Street Address

City State Zip Code


Telephone Number

E-mail Address


SITE LOCATION 7


Street Address

City State Zip Code


Telephone Number

E-mail Address


Page 6 of 15


SITE LOCATION


Street Address

City State Zip Code


Telephone Number

E-mail Address


SITE LOCATION


Street Address

City State Zip Code


Telephone Number

E-mail Address


SITE LOCATION


Street Address

City State Zip Code


Telephone Number

E-mail Address


Page 7 of 15

ACCREDITATION FEES WORKSHEET F I N D N S H S M E T H O D S CO D E S : S E E D H E A L T H . O R G

Site # Pathogen Test Code Accredita�on Fee

1 # Click or tap here to enter text Enter Code $3,000 minimum fee: 6 tests or less

2

3

4

5

6

7 $250 for each addi�onal test

8

9

10

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12

13

14

15

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25

TOTAL FEES Total Fees for Op�on 1

OPTION 1: Seed Health Tes�ng

Page 8 of 15

ACCREDITATION FEES WORKSHEET (ADDITIONAL WORKSHEETS PAGES 9-12)

Site # Site Name (State) Enter Site Name Here

List of Crops: Accredita�on Fee

1 Click or tap here to enter name of crop $2000 per site loca�on

2 $250 for each addi�onal crop

3

4

5

6





3

4

5

6

TOTAL FEES Total Fees for Op�on 2

LABORATORY PROVIDING DIAGNOSTIC SERVICES

Laboratory Name Click or tap here to enter text


Street Address

City State Zip Code

Telephone Fax Email Address

OPTION 2: Phytosanitary Inspec�on

Page 9 of 15

ACCREDITATION FEES WORKSHEET (CONTINUE D)





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Page 10 of 15






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Page 11 of 15






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Page 12 of 15






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Page 13 of 15

ACCREDITATION FEES WORKSHEET

Site # Site Name (State) List of Crops # of Inspectors

# Enter site name here Name of crop here Enter #

TOTAL FEES $1000 Flat Fee

OPTION 3: Seed Sampling for Seed Health Tes�ng

Page 14 of 15

ACCREDITATION FEES WORKSHEET

Site # Site Name (State) List of Crops # of Inspectors

# Enter site name here Name of crop here Enter #

TOTAL FEES $1000 Flat Fee

LABORATORY PROVIDING DIAGNOSTIC SERVICES

Laboratory Name Click or tap here to enter text


Street Address

City State Zip Code

Telephone Fax Email Address

OPTION 4: Visual Inspec�on of Seed for Phytosanitary Cer�fica�on

Page 15 of 15

APPLICATION SUBMISSION CHECKLIST

STEP 1

☐ Submit a non-refundable $400 deposit check payable to USDA

☐ Sign and Submit all completed Accredita�on Applica�on forms to:

Sarika NegiAccredita�on and Cer�fica�on Policy Manager Tele: 301.851.2349Plant Health Programs – Export Services E-mail: [email protected] River Road, Unit 131 Riverdale, MD 20737-1236

STEP 2

☐ Submit a non-refundable $600 deposit check payable to Iowa State University

☐ Submit a copy of your Quality Manual

☐ Submit a copy of all completed Accredita�on Applica�on forms to:

Gary MunkvoldNSHS Administra�ve Unit Tele: 515.294.7560160 Seed Science Center Fax: 515.294.2014Iowa State University E-mail: [email protected] Osborn Drive Website URL: seedhealth.org Ames, IA 50011

STEP 3

Upon approval of your applica�on by USDA-APHIS, you will be contacted by the NSHS Accredita�on Unit with further instruc�ons on the accredita�on process and billing for the total accredita�on fee and auditor fees.

☐ OPTION 1 Total fees from Accredita�on OPTION 1: Page 7 $ Total or N/A ☐ OPTION 2 Total fees from Accredita�on OPTION 2: Page 8 $ Total or N/A ☐ OPTION 3 Total fees from Accredita�on OPTION 3: Page 13 $ Total or N/A

☐ OPTION 4 Total fees from Accredita�on OPTION 4: Page 14 $ Total of N/A

** If reques�ng tests from both OPTION 1 & OPTION 2: Subtract $1000 **Subtract $1000 TOTAL FEES $ Total Fees

STEP 4

☐ Company or Organiza�on Authorized Signature

SIGNATURE: ________________________________________________________________

Legal Name: Title: Date:

ADJUSTED TOTAL $ Adjusted Total Fees

Documents

ACCREDITATION APPLICATION FORM - NSHSseedhealth.org/wp-content/uploads/2017/04/NSHS-New... · Plant Health Programs – Export Services E-mail: [email protected] 4700 River