Form APHIS 2001 APHIS 2001 APPLICATION FOR US VETERINARY BIOLOGICS ESTABLISHMENT LI

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This application must be submitted for issuance of a U.S. Veterinary Biologics Establishment License. The information will assist in determining the qualifications of the establishment to prepare biological products (9 CFR 102).
U.S. DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE VETERINARY SERVICES, CENTER FOR VETERINARY BIOLOGICS APPLICATION FOR UNITED STATES VETERINARY BIOLOGICS ESTABLISHMENT LICENSE						FOR VETERINARY BIOLOGICS USE ONLY
						ESTABLISHMENT LICENSE NUMBER
INSTRUCTIONS: Submit one copy of application for each establishment. If additional space is needed, attach additional sheets and refer to Item No. Enclose documents specified in 9 CFR 102.3.			1. TYPE OF APPLICATION ("X" one) INITIAL CHANGE OF LICENSE					2. DATE SUBMITTED
3. NAME AND ADDRESS OF APPLICANT (Include No., Street or RFD Number, City, State, ZIP Code)					4. ADDRESS FOR OFFICIAL MAIL FROM VETERINARY BIOLOGICS
5. IF INITIAL APPLICATION, ATTACH A COMPLETED APHIS Form 2003 FOR ONE PRODUCT. NAME THE PRODUCT	6. IF CHANGE OF LICENSE, EXPLAIN PURPOSE OF CHANGE
7. TYPE OF ORGANIZATION ("X" one) CORPORATION PARTNERSHIP INDIVIDUAL PROPRIETORSHIP				8. IF CORPORATION, GIVE STATE IN WHICH INCORPORATED (Enclose a certified copy of articles of incorporation, if not previously filed)
9. PRINCIPAL OFFICERS OR PARTNERS
A. NAME OF EACH	B. TITLE			C. BUSINESS ADDRESS
10. IDENTIFY EACH SUBSIDIARY TO OPERATE IN THE ESTABLISHMENT (Enclose a certified copy of articles of incorporation and a letter of approval signed by an authorized officer of each subsidiary named, if not previously filed)				11. LIST NAME OF EACH MARKETING DIVISION
A. NAME OF EACH SUBSIDIARY AND LOCATION (if different from Item 3)	B. STATE IN WHICH INCORPORATED
12. LIST THE LOCATION OF ALL PREMISES TO BE USED FOR PREPARATION, TESTING, AND INITIAL SHIPPING (if different from Item 3)
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 license to maintain an establishment for the preparation of animal biological products for the use in the treatment of domestic animals. If a license is issued by the United States Department of Agriculture under this application, the licensee expressly agrees to comply with the provision of the said Act, and all rules, regulations, and orders of the Department issued pursuant thereto relating to the operation of such establishment and the preparation, testing, and distribution of animal biological products prepared therein, and that the animal biological products will not be labeled or advertised so as to mislead or deceive the purchaser in any particular.
13. SIGNATURE OF AUTHORIZED OFFICIAL		14. TITLE					15. DATE SIGNED

APHIS FORM 2001 Previous editions are obsolete.

OCT 2011