IFAS
North Florida Research and Education Center
Plant Pathology Department 
Florida Extension Plant Diagnostic Clinic - Quincy
155 Research Road, Quincy, FL 32351     Tel: (850) 875-7140   Fax: (850) 875-7188
        wadan@mail.ifas.ufl.edu               tmomol@ufl.edu
 SAMPLE SUBMISSION FORM
Grower
Submitted By (If different)
Name: Name:
Address: Address:
.. .
. County:
E-mail:....................... E-mail:
Phone:                                Fax:  Phone:                                           Fax:
Host Plant:...............  Cultivar:.....    ..... DDIS #:
Select one:   Commercial Grower [ ]  Consultant [ ]  Home Grower [ ]   Research [ ]
A fee of $20.00 is required per sample. 
Symptoms: Circle most appropriate choice or provide your own description.
Roots:  galled,  brown,  tissue sloughing off,  other:
Stem/Branch:  cankers,  girdled,  dark lesions,  other:
Leaves:  mottled,  mosaic pattern,  chlorotic spots,  necrotic spots,   colored spots,  other: 
Flowers/Fruit:  necrotic,  chlorotic,  scabby,  uneven ripening,  other:
Overall plant appearance :  stunted,  elongated,  gnarled,  wilted,  other:
How long have symptoms been present?
Located:  Field [ ]                Nursery [ ]               Grove/orchard [ ]            Landscape [ ]
Garden [ ]            Greenhouse [ ]       Forest [ ]        Interior [ ]    Other_______________
Prevalence:    Entire Planting [ ]             Localized Area [ ]         Scattered Area [ ]
Recently Applied Fertilizers: 
Recently Applied Pesticides:
Recent Cultural Practices:
For Clinic Use Only
Date Received  Comments..................... Sample No: 200_ -- 

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