Submission Form

PLANTOVITA – DIAGNOSTIC SAMPLE REGISTRATION FORM

DIAGNOSTIC SAMPLE REGISTRATION FORM

Lab Reg No

Plantovita is obliged by law to report the presence of regulated and quarantine pathogens to the applicable authorities

PRODUSENT / PRODUCER

(Verantwoordelik vir betaling tensy anders aangedui \ Responsible for payment unless indicated otherwise)

KONTAKPERSOON / CONTACT PERSON

(Indien anders as Produsent \ If Different from Producer)

Naam / Name

Adres / Address

Adreslyn 1 / Address Line 1

Adreslyn 2 / Address Line 2

Stad / City

Poskode / Postal Code

Tel

Faks / Fax

Naam / Name

Adres / Address

Adreslyn 1 / Address Line 1

Adreslyn 2 / Address Line 2

Stad / City

Poskode / Postal Code

Tel

Faks / Fax

Landdrosdistrik / Magisterial District

Eenheid No / Unit No

Besproeiing of Droëland / Irrigation or Dry Land

Kliënt Monster No / Client Sample No

Aantal Houers / No of Containers

Geregistreerde Aanplanting / Registered Planting

Geregistreerde Kommersiële Aanplanting / Registered Commercial Planting

ONDERSOEK VERLANG / EXAMINATION REQUIRED

Beskrywing van monster / Description of sample

Gewas / Crop

Variëteit / Variety

Monstertipe / Type of Sample

Beskrywing van simptome in die geval van siektetoetse / Description of symptoms in the case of disease tests

VERKLARING DEUR KLIËNT / DECLARATION BY CLIENT

Hiermee bevestig ek, die ondergetekende, dat meegaande monster uit die eenheid/lot met besonderhede soos hierbo aangedui, getrek is. /

I, the undersigned, hereby declare that the accompanying sample was drawn from the unit/batch in respect of which particulars are furnished above.

Ingedien deur / Submitted by

Geteken / Signed

Deur hierdie kliek teken u die vorm en aanvaar u die verklaring / By checking this box you are signing this form and accepting the declaration

Datum ingedien / Date submitted

VERKLARING DEUR PLANTOVITA / DECLARATION BY PLANTOVITA

Die uitslag van die laboratorium is slegs van toepassing op die monster(s) wat ingedien is en die laboratorium is nie verantwoordelik vir die akkuraatheid of uniformiteit van die monster(s) nie.

The Laboratory results are only applicable to the sample/s received and the Laboratory is not responsible for the accuracy and uniformity of the sample(s)

In accordance with the Protection of Personal Information Act, 4 of 2013 (“POPIA”) any personal information contained in this document will be kept confidential and processed only for the purpose it was intended for. Any data subject (“Person”) that objects to the information being processed and/or withdraws their consent must notify the company in writing.