Request for Canadian Grain Commission onsite service:

railcars, trucks or containers

Date of request (dd/mm/yyyy) / Person requesting service:
Licensed company name requesting service: / Name and Address of loading facility
CGC service requested Inspection Sampling
Weighing / Destination of shipment:
Shipping Date (dd/mm/yyyy) / Start Time / Estimated completion time
Origin of grain: / Canadian / Imported / Mixed Canadian and Imported
Has the grain been fumigated within the last 10 days? / Yes
No / If yes, date fumigated applied:
“The shipper declares that the grain has been treated in accordance with the product label directions”.
(Authorized signature): ______
ConveyanceInformation: complete applicable section A, B, or C
Section A: railcars / Section B: containers / Section C: trucks
No. of railcars: / No. of containers: / Bagged
Bulk / No. of trucks:
Grain/ Grade: / Grain/ Grade: / Grain/ Grade:
Commercially clean
Not commercially clean / Identification:
/ If applicable, no. of bags per container: / Commercially clean
Not commercially clean
Do you require any sealed sample requests as part of the representative sample taken? / Yes
(Complete section D) / No
Section D: request for sealed samples: (list all sample requirements)
1 / Identification: / Number of samples: / Sample size requested:
Recipient and complete mailing address to send the sample to: / Postal Code
2 / Identification: / Number of samples: / Sample size requested:
Recipient and complete mailing address to send the sample to: / Postal Code
Sealed samples will be couriered as requested above. Courier fees will be invoiced to the client unless otherwise specified: / Courier Company
Account Number
Do you require additional sample to be procured for testing by the CGC? / Yes
(specify below) / No
If yes, specify sample size to be procured and requested testing.
i.e. 1000 grams for entomology testing
Other information:
For Canadian Grain Commission use only
Date received: / Time received:

I-33CGCIndustry Services - ISO 9001 - Services à l'industrie CCG2013-08