AGWEST Plant Laboratories
3 Baron-Hay Court
South Perth WA 6151
PH: +61 (0)8 9368 3721
FAX +61 (0)8 9474 2658
Form 101
A
Broadacre Plant Disease Diagnosis
Contact details of party responsible for all charges
Trading name
ABN
Address
Postcode
Full name
Phone
Note: A phone number or fax number or email must be provided if available
E-mail
Fax
Mobile
Signature
Date
B
Complete the following if a duplicate copy is required to another party
E-mail
Fax
Please mail
Name
Address
E-mail
Postcode
C
Type of sample
Seed
Whole Plant
Leaves
Cultivar
Crop species
Roots
D
Tops
Sowing date
Sample ID
Number of samples
Soil
For best results despatch
sample on Mon-Wed
Sampling date
Describe the problem (include descriptions of different samples, e.g. affected / unaffected)
Distribution is:
Uniform across paddock
Proportion of paddock affected
Scattered
Patches < 3m
Value of crop production (optional)
Patches > 3m
$
Protecting agricultural industries
Free test (x)
I believe this pest is a new threat
to Western Australia
to this region of the state
Issue No. 4 160414
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E
Production details
Soil type
Tillage (current season)
Light (sand / sandy loam)
Pre-plant
Medium (loamy)
Conventional
Heavy (clay / clay loam)
Min-till full cut
Gravel
Min-till knife point / or disc
Duplex < 30cm to clay
Other (e.g. deep ripped)
Comments
Paddock treatment (current season)
Treatment
Date
(Fertiliser, spray etc.)
Duplex > 30cm to clay
Free draining
Pre, at or
post planting
Rate / ha
Prone to water logging
pH in CaCl2
pH in H2O
Paddock rotation
Last year
2 years ago
3 years ago
F
Seasonal conditions that may be relevant to the symptoms. Check appropriate box for each month.
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Frost
Dry
Good
Wet
Additional comments
Free Delivery Instructions
Despatch samples in enclosed postal bag at any WA Post Office.
If not using the AGWEST Plant Laboratories despatch bag, address your sample to:
AGWEST Plant Laboratories
Department of Agriculture and Food
Reply Paid 83377
3 Baron-Hay Court
South Perth WA 6151
This form is available on the APL home page
agric.wa.gov.au/agwestplantlabs
Issue No. 4 160414
Page 2 of 2