APHIS Form 2005 Application for United States Veterinary Biological Prod

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This application must be submitted for issuance of a United States Veterinary Biological Product Permit. This information will be used to determine if the product may be brought into the United States,
or for approval of transit shipment of biological products move through the United States (9 CFR 104). INSTRUCTIONS: Submit an application for each product. If more space is needed, attach
additional sheets and refer to block number. Enclose supporting documents.
UNITED STATES DEPARTMENT OF AGRICULTURE
USDA PERMITTEE NUMBER (LEAVE BLANK FOR INITIAL APPLICATIONS)
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES, CENTER FOR VETERINARY BIOLOGICS

APPLICATION FOR
UNITED STATES VETERINARY BIOLOGICAL PRODUCT PERMIT
INITIAL

1. DATE SUBMITTED

RENEWAL

2. TYPE OF APPLICATION
RESEARCH AND EVALUATION
(Complete all items except 10 through 15)

GENERAL SALE AND DISTRIBUTION
(Complete all items except 6, 7, 8, 9, and 15)

TRANSIT SHIPMENT ONLY
(Complete all items except 9 through 14)

3. NAME AND ADDRESS OF APPLICANT (Include Number, Street or RFD Number, City, State, and ZIP Code) 4. NAME AND ADDRESS OF PRODUCER

5.NAME OF PRODUCT (one only)
6. ESTIMATED ARRIVAL DATE

FOR EACH SHIPMENT OF SAME PRODUCT GIVE
7. ESTIMATED QUANTITY
8.UNITED STATES PORT OF ENTRY

9.IF PRODUCT IS FOR RESEARCH AND EVALUATION, FURNISH NAME AND LOCATION OF INSTITUTION DOING RESEARCH (If same as Item 3, so state. Enclose brief description of product;
methods of propagation including composition of medium; species of animals or cell cultures used; method of inactivation or attenuation; recommendation for use; and proposed plan of evaluation
pursuant to 9 CFR 104.4(a).)

10.IF PRODUCT FOR GENERAL DISTRIBUTION AND SALE (Enclose manufacturer's or producer's agreement regarding preparation, testing, and labeling of products, and inspection facilities.
Enclose supporting documents specified in 9 CFR 104.5.))
11.ADDRESS OF STORAGE FACILITIES (If different from Item 3)

12. TYPE OF ORGANIZATION
CORPORATION

PARTNERSHIP

INDIVIDUAL

13. IF CORPORATION, GIVE STATE IN WHICH INCORPORATED (Enclosed certified
copy of Articles of Incorporation)

14. PRINCIPAL OFFICERS OR PARTNERS
A. NAME OF EACH

A. DESTINATION

B. TITLE

C. BUSINESS ADDRESS
(Include Number and Street, or RFD Number, City, State, and ZIP Code)

15.IF TRANSIT SHIPMENT GIVE
B. CARRIER(S)
Arrival

C. SCHEDULE (Dates in transit)
Departure

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 permit to import the herein named
biological product for the purpose specified in item 2 above. If a permit is issued under this application, the recipient expressly agrees to conform strictly to all rules,
regulations and orders of the Department governing the importation of veterinary biological products and that the product will not be labeled or advertised so as to mislead or
deceive in any particular.
16. SIGNATURE OF AUTHORIZED OFFICIAL

APHIS FORM 2005
APR 2015

17. TITLE

Previous editions are obsolete.

18. DATE SIGNED