Aphis 2020 Ahipment And Receipt Of Biologics Samples

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 0.3 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 report is required by Regulation (9CFR 113). Failure to report can result in no certification for authenticity of samples of products.

UNITED STATES DEPARTMENTDF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECT10N SERVICE SHIPMENT AND RECEIPT OF BIOLOGICS SAMPLES

1. DATE SUBMITTED

2. FIRM LICENSE NUMBER

3. NAME AND MAILIND ADDRESS OF FIRM (Include ZIP Code)

Instructions: Submit original and one copy with samples

4. PURPOSE ROUTINE CONCURRENT SAMPLE MASTER SEED CELL LINE PRELICENSING SAMPLE RETENTION SAMPLE RESUBMSSION (Specify In Remarks) OTHER (Specify In Remarks)

5. HOW II PRODUCT SHIPPED DRY ICE REFRIDERATED UNREFRIGERATED

OTHER (Specify)

PRODUCT IS SHIPPED VIA

6. PRODUCT NAME (No trade name) SERIAL (Only one entry per line)

7. PRODUCT CODE

8. SERIAL NUMBER

9. SAMPLE CODE (For Gov’t Use Only)

SAMPLE CONTAINERS SUBMITTED

13. INDICATE BULK OR FINAL

10. NUMBER

11. SIZE

12. FIELD DOSE

I certify that I am an authorized government sampler and the samples listed above were selected and are submitted in accordance with 9 CFR 113.3.

16. REMARKS

14. SIGNATURE OF AUTHORIZED GOVERNMENT SAMPLER TELEPHONE NUMBER ( ) -

15. DATE

ACKNOWLEDGMENT OF RECEIPT OF SAMPLES

17. CONDITIONS AND REMARKS

18. RECEIVED BY (Signature)

19. DATE RECEIVED

APHIS FORM 2020 Previous editions are obsolete.

OCT 2011

Instructions for APHIS FORM 2020

SHIPMENT AND RECEIPT OF BIOLOGICAL SAMPLES

This form is used by Veterinary Biological Licensees and Permittees to submit samples to the Center for Veterinary Biologics for testing.

Submitters must complete items 1-8, and items 10-16. Items 9, 17-19 are for Agency use.

Submit one copy with original signature and the samples to the address below. A photocopy of the submission form with items 9, 17, 18, and 19 completed will be returned to the submitter via mail.

Center for Veterinary Biologics

NVSL, BMPS - Sample Repository

P. O. Box 844

1800 Dayton Avenue

Ames, Iowa 50010