Name of Processing/Cleaning Facility: 
Address of Facility (physical location receiving product):
Name Facility Contact:
Telephone Number of Facility Contact:
Commodity
Grain or Seed for Cleaning: Yes No (If Yes, complete part A below)
Screenings: Yes No (If Yes, complete part B below)
Source (U.S. State of Origin):
Volume (e.g. No. of Truckloads):
Period of Importation: (Maximum of one year)
A. If importing Grain or Seed for Cleaning
Commodity names:
Describe transportation, handling and storage conditions of grain or seed prior to cleaning to prevent spills, scattering or unauthorized spread:
Identify the location and method of disposal or processing of screenings derived from cleaning of imported grain or seed (e.g. burning, burial, shipping to a processing plant for pelleting or milling for animal feed):
Describe handling and storage conditions for screenings derived from cleaning of imported grain or seed, including during transportation to disposal site:
B. If importing screenings or handling screenings produced from cleaning imported seed or grain
Describe transportation, handling and storage conditions of screenings to prevent spills, scattering or unauthorized spread:
Identify method to be used by facility to process screenings (e.g. pelleting or milling):
Approval by a CFIA inspector is required before a Permit to Import will be issued authorizing movement to the cleaning or processing facility of imported grain or seed for cleaning or imported screenings.
Applicant's statement:
I agree to act as the person responsible for the above facility's management of foreign origin screenings.
I have read and agree to comply with the provisions of D-96-07. In particular, I agree:
- To route imported material to the facility and process it as soon as possible following arrival.
- To transport imported material and screenings derived from this material in such a manner as to prevent spills, scattering or unauthorized spread.
- To inform the local CFIA office if spills occur while in transit to the facility.
- To not sell or distribute imported material until processed at the facility in the manner approved by the CFIA inspector.
- To ensure that third parties contractors that I engage comply with the requirements of D-96-07.
I have read and understand all conditions in the above statement.
Dated: at: Province:
Applicant's Signature
Name Printed
The following section must be completed by a CFIA Inspector designated under the Plant Protection Act
Approved for:
A. Receipt of Grain or Seed for Cleaning: Yes No
B. Receipt of Screenings: Yes No
CFIA Inspector
Date
Name Printed
CFIA Office