SureSeed®Program

SureSeed®Grower Declaration and Request for Seed Analysis

This form is to accompany the seed lot to the Authorised Seed Processor and then accompany the official sample to theSeed Testing Station at the Department of Agriculture and Food Western Australia, 3 Baron-Hay Court, South Perth WA 6151. For assistance phone (08) 9368 3721.

Note: A copy of this form may be provided to the Licensee of the variety.

Please print all information

Part A:Full name, residential and postal address of person responsible for all charges
Full name: / Signature:
Residential address: / Postcode:
Postal address: / Postcode:
Telephone: / Fax: / E-mail:
For additional copy(ies) of analysis certificate(s) please tick preferred method to receive certificate
(Note – cost of additional hard copy certificates to be paid by person receiving certificate)
Full name: / E-mail:
Fax: / Post:
Part B:To be completed and signed by theOwner/Manager of the property on which the seed was harvested
I declare that the Variety: / Generation:
seed described on the reverse of this form was harvested from Registered Area Number
paddock name / .
The approximate production from the area was: / tonnes.
All equipment used to harvest, transport and store the seed was cleaned, inspected and free of contamination prior to use.
Name: / Signature: / Date:
Part C:This part is to be completed and signed by the person in charge of the Authorised Seed Processor
I declare that the seed delivered to this facility and described on the reverse of this form
a) was unloaded and stored in facilities that were cleaned, inspected and free of contamination;
b) that all machinery used to clean this seed was cleaned, inspected and free of contamination prior to grading.
Name: / Signature: / Date:
All samples will receive full testing required by the SureSeed®Program.
Seedlot 1 / Seedlot 2 / Seedlot 3
Seed lot code
Mass of each container (kg)
Number of containers
Total mass of seed lot (kg)
SureSeed label no. From:
SureSeed label no. To:
Sampling date
Chemical additives
Exclude protein profile / Exclude / Exclude / Exclude
Note: One protein profile test is required for each SureSeed paddock of wheat, barley and oats. If multiple seed lots come from one paddock, the protein profile test may be excluded for subsequent samples.
Part D:To be completed and signed by the Authorised Seed Sampler
The above seed was sampled in accordance with the specifications of the SureSeed® Program.
Name: / Signature: / Date:

Free delivery instructions

Despatch samples in enclosed postal bag at any WA Post Office.

If not using the AGWEST Plant Laboratories despatch bag, address your sample to:

AGWEST Plant Laboratories
Department of Agriculture and Food
Reply Paid 83377
3 Baron-Hay Court
South Perth WA 6151

This form is available on the APL home page

agric.wa.gov.au/agwestplantlabs

Issue No. 6 070214 / Page 1 of 2 / Form No. 709