VS 11-1 Application for Enrollment in the National Chronic Wasti

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 0579-0189. The time required to complete this information collection is
estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintain the data needed, and
completing and reviewing the collection of information.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

OMB Approved
0579-0189
EXP.: XX/XXXX

APPLICATION FOR ENROLLMENT IN THE FEDERAL CHRONIC WASTING
DISEASE VOLUNTARY HERD CERTIFICATION PROGRAM FOR FARMED AND
CAPTIVE CERVIDS
A. Owner Information

1. Owner’s Name:
2. Mailing Address:

3. City:

4. County:

7. Business Phone Number:

5. State:
8. Cell Phone Number:

6. ZIP Code:
9. Business Fax Number:

10. Email Address:
B. Facility Information
11. Facility Name:
12. * Premises Identification Number (PIN):
13. Address:

14. City:

15. County:

18. Business Phone Number:

16. State:
19. Cell Phone Number:

17. ZIP Code:
20. Business Fax Number:

21. Business Email Address:
Mailing address, if different from above:
22. Street or P. O. Box:

23. City:

24. County:

25. State:

26. ZIP Code:

27. County:
28. Manager’s Name (if applicable):
29. Manager’s Cell Phone Number:

30. Number of Elk:

C. Breed
31. Number of Red Deer:

32. Number of Moose:

33. Number of White-Tailed Deer:

34. Number of Mule Deer:

35. Number of Black-Tailed Deer:

36. Number of Other Species (list all types):

I have received a copy of the National Chronic Wasting Disease Voluntary Herd Certification Program in farmed and captive cervids and wish to participate in the
program as described therein.
I understand that it is my responsibility to meet the requirements of the program and all other applicable State and/or Federal laws that pertain to my facility.
I also understand that my herd enrollment may be suspended or cancelled for non-compliance or failure to document compliance with the program requirements.
This may also affect my herd’s certification status level.
37. Signature of Owner or Authorized Agent:
38. Date:

39. Signature of Authorized APHIS Representative:

40. Date:

Your herd “Enrollment Date” for participation in the Herd Certification Program will be determined by APHIS upon receipt of this signed Application for
Enrollment in the National Chronic Wasting Disease Voluntary Herd Certification Program for Farmed and Captive Cervids (VS Form 11-1), the
completed initial whole herd inventory, and documentation showing that all animals in the herd, 12 months of age and older, were inspected and
inventoried within the previous 12 months.
* A unique number assigned by a State or Federal animal health authority to a premises that is, in the judgment of the State or Federal animal health authority, a
geographically distinct location from other livestock production units.
For further assistance, contact your State Area APHIS office.
Mail all documents to your State Area APHIS office.
For animal co-owners or herds that are distributed between multiple facilities, please complete a VS Form 11-1A.
VS Form 11-1
AUG 2012