Aphis 2018 Request For Reference, Reagent, Or Reagent Seed Material

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0579-0013. The time required to complete this information collection is estimated to average 0.1 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.										OMB Approved 0579-0013 EXP. DATE XX/XXXX
This certificate is required for foreign countries to furnish official certification by the Veterinary Services the certain products have been prepared in accordance with Virus-Serum-Toxin Act (9 CFR 112).
UNITED STATES DEPARTMENTDF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECT10N SERVICE VETERINARY SERVICES CENTER FOR VETERINARY BIOLOGICS (CVB)				INSTRUCTIONS: Submit in triplicate to: USDA-APHIS-VS Center for Veterinary Biologics Inspection and Compliance 1800 Dayton Avenue, P.O. Box 844 Ames, IL 50010			REQUEST FOR REFERENCE, REAGENT, OR REAGENT SEED MATERIAL (Only one reference, reagent, or seed material on each form.)
Request
REQUESTING FIRM's NAME:	COMPLETE MAILING ADDRESS (Number P.O. Box):					DATE OF REQUEST:		LICENSE OR PERMIT NUMBER:
PHONE NO. (Needed for shipping):
REAGENT REQUESTED:	CVB NOTICE ISSUE DATE:				QUANTITY REQUESTED:	PURPOSE OF REFERENCE:
NAME OF COURIER:			REMARKS:
COURIER ACCOUNT NUMBER (For shipping to be charged):
NAME AND TITLE OF PERSON MAKING REQUEST:			SIGNATURE:						DATE:
REPLY
AMOUNT SHIPPED LOT NUMBER:			REMARKS:
A. NUMBER OF CONTAINERS:
B. VOLUME OF EACH CONTAINER:
C TOTAL VOLUME.
REFRIGERATION: YES NO		DATE SHIPPED:	SHIPPED BY:
NAME AND TITLE OF CVB OFFICIAL:			SIGNATURE:						DATE:
RECEIPT
AMOUNT RECEIVED:			REMARKS:
A. NUMBER OF CONTAINERS:
B. TOTAL VOLUME:
CONDITION OF SHIPMENT:		DATE SHIPPED:
NAME AND TITLE OF PERSON WHO RECEIVED SHIPMENT:			SIGNATURE:						DATE:

APHIS FORM 2018 USE THIS FORM FOR REQUESTING CVB REAGENTS ONLY

OCT 2011