APHIS PPQ Permit # P526P-19-02121 PDC Staff Only:

UF Plant Diagnostic Center City/Co.

Bldg 1291, 2570 Hull Rd
Gainesville, FL 32611-0830 USA PDC #:
Carrie L. Harmon, Plant Pathologist
pdc@ifas.ufl.edu Date:
Phone +1 352 392 1795 Ship type:

Plant Disease Diagnosis Form (#2901) pmt:

If resubmission, indicate original sample #: APHIS Red-and-White Label #:
Please Print- fill in ALL relevant data; maintain office copy; submit original copy with specimen. Revised 5/24/2019

Submitter Information: Client/Grower Information:

$200 per
Name or reference ID: sample; include
payment info
Company:
below
Address:

City/Zip: We accept credit

card payments over
Phone No.
the phone, please
do not email credit
Fax No.:
card info.
Email:

Submitter Client 3rd party Indicate account name here if using prepaid credit:
Email reply to:
Bill to: ________________________________________
Third party email: _______________________________________ (bill and receipt will be sent to this account)
City and country of
sample origin: Date Sample Collected: Date Sent to Lab:
Plant and Site Information
Plant & Variety/Cultivar:
Planting Type: Field Interior Forest Garden Grove/Orchard Landscape Nursery Greenhouse Other:

Irrigation type and frequency

Pesticides applied past 45 days:
Soil type: Sandy Clay Silt Loam Organic Soil pH (acid/basic)

Size of planting: % Plants Affected: Date symptoms first noticed:

Describe the problem. Include symptoms, plant parts affected, pattern of occurrence, etc. Attach separate sheets if necessary.

Credit card information

(this part of the form will be detached and shredded after card has been run; we do not keep this information on file)

Credit card or check number:

Credit card expiration date (mm/dd/yy): Billing phone #:

3-digit code on back of credit card:

Name as it appears on credit card:

If you prefer to pay by Electronic Funds Transfer, please see the EFT Form
The Institute of Food and Agricultural Sciences (IFAS) is an Equal Opportunity-Affirmative Action Employer authorized to provide research, educational information and other services only to individuals and institutions that function
without regard to race, color, sex, age, disability, or national origin. U.S. Department of Agriculture, Cooperative Extension Service, University of Florida, IFAS, Florida A & M University Cooperative Extension Program, and Boards of
County Commissioners Cooperating. 5-24-19