PERMIT #: ___________ P. I.: ______________________________  ETA: _______________

POINT OF ORIGIN: _______________________________________________________________

 ________________________________________________________________________________

 ________________________________________________________________________________

SOURCE: _______________________________________________________________________


CONTENTS:		GENUS				SPECIES

NATURAL ENEMIES	___________________________     __________________________
								
HYPERPARASITES	___________________________     __________________________

		___________________________     __________________________	

HOST INSECTS	___________________________     __________________________

		___________________________     __________________________

		___________________________     __________________________


HOST PLANTS	___________________________     __________________________
				
PACKAGING	___________________________     __________________________	

		___________________________     __________________________


EMERGENT MATERIAL TO BE:

_____ CONSIGNED TO P. I.     _______ PROPAGATED TO DETERMINE REPRODUCTIVE STATUS

_____ FORWARDED TO: __________________________________________________________________

DEAD ORIGINAL MATERIAL TO BE PASSED TO:

__________________________________          P. I.      _______________________________
TAXONOMISTS

DATE OF NOTICE: ______________________________________________________________________

SIGNATURE ____________________________________________________________________________

AUTHORIZATION FOR THE FOLLOWING PERSON(S) TO ENTER DESIGNATED SPACE IN QUARANTINE
TO MONITOR THE PREVIOUSLY DESCRIBED SHIPMENT IS REQUESTED, 

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________P. I. 

______________ APPROVED      _________________ NOT APPROVED

_________________________________________QUARANTINE SUPERVISOR