VS 1-27 APR 2009.d Permit for Movement of Restricted Animals

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 numbers for this information collection are 0579-0047 (signature only), 0579-0070, 0579-0101, 0579-0148, 0579-0185, 0579-0234, and 0579-0340. The time required to complete this information collection is estimated to average between .033 hours and 2 hours. These times include time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

OMB Approved 0579-0047, 0579-0070, 0579-0101, 0579-0148, 0579-0185, 0579-0234, and 0579-0340

This permit identifies restricted animals moved for quarantine/slaughter purposes. The information is needed to identify disease infected/exposed animals that are moved to specific locations in order to control and prevent spread of the disease (9 CFR 71 through 85).

See reverse side for additional information.

UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE VETERINARY SERVICES PERMIT FOR MOVEMENT OF RESTRICTED ANIMALS USE A SEPARATE FORM FOR EACH SPECIES

NO.

5. STATE WHERE ISSUED

1. NAME AND ADDRESS OF SHIPPER OR CONSIGNOR (Include Zip Code)

6. MOVEMENT TO BE INTERSTATE INTRASTATE

7. MOVEMENT FOR QUARANTINE SLAUGHTER

2. CONSIGNEE (Destination Name and Address, include Zip Code)

8. DISEASE

9. STATUS OF ANIMALS

No. Reactor

No. Exposed

No. Other (Specify)

3. MOVED FROM (Name and Location of Premise if other than item 1 above)

10. STATUS OF HERD OF ORIGIN

11. STATUS OF AREA OF ORIGIN

4. NAME AND ADDRESS OF OWNER AT TIME CONDITION DIAGNOSED

12. NO. ANIMALS IN THIS SHIPMENT

13. SPECIES (One only)

14. TRANSPORTATION VEHICLE LICENSE NO. OR OTHER IDENTIFICATION NO.

15. SEAL NO.

16. VEHICLE REQUIRED TO BE CLEANED AND DISINFECTED AT DESTINATION YES NO (If yes, items 32, 33, and 34 are applicable)

VALID ONLY FOR ABOVE DESTINATION

17. ANIMALS TO BE MOVED

COMPLETE EAR TAG NO.

BREED

SEX

DISEASE BRAND

OTHER IDENTIFICATION (Complete No.)

COMPLETE EAR TAG NO.

BREED

SEX

DISEASE BRAND

OTHER IDENTIFICATION (Complete No.)

I certify that I have inspected the animals described on this permit and find them eligible to move in accordance with the requirements of State and Federal regulations.

18. SIGNATURE OF INSPECTOR

19. DATE ISSUED

20. TIME ISSUED

VOID AFTER

21. DATE

22. TIME

WARNING TO OWNER, SHIPPER,AND TRUCKER - LIVESTOCK MUST BE DELIVERED TO CONSIGNEE WITHOUT DIVERSION. I understand that it is a violation of Federal law to move the animals identified herein interstate except in accordance with the provisions of applicable Federal Regulations. I also understand that such animals must comply with existing State laws and regulations governing movement of livestock and poultry. I have arranged or will arrange for a copy of this permit to accompany the interstate shipment and be delivered with the above described animals.

23. SIGNATURE OF OWNER OF SHIPPER

24. TITLE OWNER SHIPPER

25. DATE SIGNED

I certify that the animals described on this permit were received and slaughtered/quarantined in accordance with the requirements of the State and Federal regulations on the date indicated in item 29.

26. PLACE ANIMALS RECEIVED

27. DATE ANIMALS ARRIVED

28. NO. ANIMALS RECEIVED

29. DATE SLAUGHTERED/QUARANTINED

30. DATE AND TIME SEALS BROKE

31. AUTHORIZED SIGNATURE

32. DATE CLEANED AND DISINFECTED (if required)

33. SIGNATURE OF INSPECTOR

34. DATE SIGNED

VS FORM 1-27 Previous edition may be used.

APR 2009