Aphis 2005 Application For United States Veterinary Biological Prod

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maintaining the data needed, and completing and reviewing the collection of information.

This application must be submitted for issuance of a U.S.
Veterinary Biological Product Permit. This information will be used
to determine if the product may be brought into the U.S. ,or for
approval of transit shipment of biological products move through
the U.S. (9 CFR 104).

U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES, CENTER FOR VETERINARY BIOLOGICS

APPLICATION FOR
UNITED STATES VETERINARY BIOLOGICAL PRODUCT PERMIT

†INITIAL

1. DATE SUBMITTED

†RENEWAL

INSTRUCTIONS: Submit one copy of application for each product. If more space is needed, attach additional sheets and refer to item
number. Enclose supporting documents.
2. TYPE OF APPLICATION

†RESEARCH AND EVALUATION

†GENERAL SALE AND DISTRIBUTION

(Complete all items except 10 through 15)

†TRANSIT SHIPMENT ONLY

(Complete all items except 6, 7, 8, 9, and 15)

3. NAME AND ADDRESS OF APPLICANT (Include No., Street or RFD No., City, State, and Zip Code)

5. NAME OF PRODUCT (one only)
6. ESTIMATED ARRIVAL DATE

(Complete all items except 9 through 14)

4. NAME AND ADDRESS OF PRODUCER

FOR EACH SHIPMENT OF SAME PRODUCT GIVE:
7. ESTIMATED QUANTITY

8. U.S. PORT OF ENTRY

9. IF PRODUCT FOR RESEARCH AND EVALUATION - FURNISH NAME AND LOCATION OF INSTITUTION DOING RESEARCH (If same as Item 3, so state. Enclose brief description
of product; methods of propagation including composition of medium; species of animals or cell cultures used; method of inactivation or attenuation; recommendation
for use; and proposed plan of evaluation pursuant to 9 CFR 104.4(a).)

10. IF PRODUCT FOR GENERAL DISTRIBUTION AND SALE - (Enclose Manufacturer's or Producer's agreement regarding preparation, testing, and labeling of products, and
inspection facilities. Enclose supporting documents specified in 9 CFR 104.5).)
11. ADDRESS OF STORAGE FACILITIES (If different from Item 4)

12. TYPE OF ORGANIZATION

† CORPORATION

†

†

PARTNERSHIP
INDIVIDUAL
13. IF CORPORATION, GIVE STATE IN WHICH INCORPORATED (Enclosed certified copy
of Articles of Incorporation)

14. PRINCIPAL OFFICERS OR PARTNERS
A.

NAME OF EACH

B.

C.

TITLE

BUSINESS ADDRESS
(Include No., Street, or RFD No., City, State, and Zip Code

15. IF TRANSIT SHIPMENT GIVE:
A. DESTINATION

B. CARRIER(S)

C. SCHEDULE (Dates in transit)
Arrival

Departure

CERTIFICATION

In accordance with the Act of Congress approved March 4, 1913 (37 Stat. 832-833; 21 U.S.C. 151-158), application is hereby made for a permit to import
the herein named biological product for the purpose specified in item 2 above. If a permit is issued under this application, the recipient expressly agrees to
conform strictly to all rules, regulations and orders of the Department governing the importation of veterinary biological products and that the product will
not be labeled or advertised so as to mislead or deceive in any particular.
16. SIGNATURE OF AUTHORIZED OFFICIAL

APHIS 2005
OCT 2001

17. TITLE

Previous editions are obsolete.

18. DATE SIGNED