Plant Disease Sample Submission Form:
PLEASE PRINT OUT THIS FORM AND MAIL WITH YOUR SAMPLE

1. Contact Information (for Client):
Name: _______________________________________________ County: _____________
Mailing Address: ___________________________________________________________
City: ____________________ State: ___________ Zip Code: _______________________
Email: ________________________Phone: (_____)____________Fax: (_____)_________

Internal Contact Information (if submitted through a county extension office):
County Contact Person:______________________________Internal Reference #_________
Email: ________________________Phone: (_____)____________Fax: (_____)_________

2. Date sample was collected:_______________________

3. Images (VERY USEFUL; send digital images via email to: molsen@ag.arizona.edu)

4. Plant Information
What is the plant? ________________________________________________________

5. Problem Description
What are the symptoms you noticed (briefly describe)? How long have the symptoms been present?
________________________________________________________________________

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Brief description of physical site.
(plant exposure, root disturbance, recent construction, etc.)

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Brief description of cultural practices.
(irrigation, moves/transplants, age of plant, etc.)

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