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

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).

According to the Paperwork Reduction Act of 1985, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
is 0579-0013. The time required to complete this information collection is estimated to average 1.0 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 NO. 0579-0013
U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES, CENTER FOR VETERINARY BIOLOGICS

FOR VETERINARY BIOLOGICS USE ONLY
ESTABLISHMENT LICENSE NO.

APPLICATION FOR
UNITED STATES VETERINARY BIOLOGICS ESTABLISHMENT LICENSE
1. TYPE OF APPLICATION ("X" one)
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.
3. NAME AND ADDRESS OF APPLICANT (Include No., Street or RFD No.,
City, State, Zip Code)

5. IF INITIAL APPLICATION, ATTACH A COMPLETED
APHIS Form 2003 FOR ONE PRODUCT. NAME THE
PRODUCT.

INITIAL

PARTNERSHIP

CHANGE OF LICENSE

4. ADDRESS FOR OFFICIAL MAIL FROM VETERINARY BIOLOGICS

6. IF CHANGE OF LICENSE, EXPLAIN PURPOSE OF CHANGE

7. TYPE OF ORGANIZATION ("X" one)

CORPORATION

2. DATE SUBMITTED

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

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)
A. NAME OF EACH SUBSIDIARY AND LOCATION
(if different from Item 3)

C.

BUSINESS ADDRESS

11. LIST NAME OF EACH MARKETING DIVISION

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

APHIS FORM 2001
OCT 2001

14. TITLE

Previous editions are obsolete.

15. DATE SIGNED