[별지 제1호 서식]

Shipper Letterhead

EXPORT TO KOREA

This shipment of potatoes for processing from the State of ******** has been treated with sprout inhibitor at the recommended rate.

Packer Affidavit

I CERTIFY that the potatoes submitted for inspection for export to Korea have been treated with ( one quart of 1% active ingredient emulsion of chlorpropham per 2000lbs of potatoes ) before shipping.

Packer :

Signature :

Date:

Phytosanitary No.:

Inspector                               Date

Commodity Inspection Division