Form VS 1-63 VS 1-63 Tribal Location Identification System Implementation Req

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UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE VETERINARY SERVICES	TRIBAL LOCATION IDENTIFICATION SYSTEM IMPLEMENTATION REQUEST
TRIBE: Who will function as Animal Traceability Administrator for the tribe? This person is responsible for coordinating the animal traceability activities for the tribe including outreach, education, premises data collection, premises registration, and premises contact information updates. The Animal Traceability Administrator has the access level to perform all data administration functions for the tribe including data entry, data editing, data viewing, data searching, account and premises creation and inactivation, creating new users and contacts, and assigning of access privileges. This is the person with whom USDA communicates on the premises registration issues.
NAME:		ADDRESS:
		CITY/STATE: ZIP CODE:
PHONE: FAX:		EMAIL:
After reading the list of options, decide how your tribe would like to participate. Not every tribe needs to submit a request at this time. Submit this request form only when your tribe is ready to proceed with premises registration. Please indicate your request by checking one of the boxes below.
O ur tribe would like to implement the Tribal Premises Registration System funded by USDA. We have a dedicated database administrator and sufficient personnel for data entry and premises exception requirements.
O ur tribe would like to implement the Tribal Premises Registration System funded by USDA. We do not have a dedicated database administrator or sufficient personnel for data entry. We would like to use the following organization/company to provide these resources as an Authorized Agent of our future.
ORGANIZATION NAME:
O ur tribe would like to use the Standard Premises Registration System funded by USDA that is used by the State in which the tribe is located. We will work with the State to register our premises.
O ur tribe would like to utilize a premises registration system we have developed for ourselves with our own resources (not Federal funds). We request that USDA evaluate our system to ensure that it is compliant with the standards of animal traceability activities. If our system meets the standards, we further request that USDA provide interfaces to the National Premises Number Allocator and the National Premises Information Repository.
O ur tribe would like to utilize the premises registration system provided by a private company with which we have a memorandum of understanding or contract using our own resources (not Federal funds). We request that USDA evaluate the system to ensure that it is compliant with the standards of the animal traceability system. If the system meets the standards, we further request that USDA provide interfaces to the National Premises Number Allocator and the National Premises Information Repository.
COMPANY NAME:
Please send this request form and address any questions or comments to: John F. Wiemers Phone: 309-344-1942 USDA, APHIS, VS Fax: 309-344-1489 2100 S. Lake Storey Road John.F.Wiemers@aphis.usda.gov Galesburg, IL 61401 Certification of Authorized Tribal Representative: I hereby certify that this request is authorized according to the laws governing our tribe.
Name:		Title:
Signature:
Phone:		Date:

VS Form 1-63

OCT 2010