Application For a Permit to Import a Dog Inadequately Im

FORM APPROVED
OMB NO. 0920-0134
EXP DATE XX/XX/XXXX

APPLICATION FOR A PERMIT TO IMPORT
A DOG INADEQUATELY IMMUNIZED AGAINST RABIES
Guidance for completing this form is available at http://www.cdc.gov/animalimportation/. This form may be
submitted electronically or by postal mail to the Centers for Disease Control and Prevention, Quarantine and
Border Health Services Branch. Mailing Address: 1600 Clifton Road NE, Mailstop E-03, Atlanta, GA 30329.
E-mail: cdcanimalimports@cdc.gov.

SECTION A – APPLICANT
1. Last Name:

2. First Name:

3. Middle Initial:

4. Mailing Address:

5. City:

6. State:

7. Zip Code:

8. Phone:

9. E-mail:

10. Passport/U.S. Driver’s License #:

11. Country/State Issued by:

SECTION B – PERMIT HOLDER (if different from above)
12. Last Name:

13. First Name:

14. Middle Initial:

15. Mailing Address:

16. City:

17. State:

18. Zip Code:

19. Phone:

21. Passport/Driver’s License #:

20. E-mail:

22. Country/State Issued by:

SECTION C – IDENTIFICATION OF DOG
23. Country of Origin:

24. Length of time (in months) in country of origin:

25. Date of Birth (MM/DD/YY):

26. Sex:

27. Breed:

28. Color (attach photograph)

29. Microchip # (if available):

30. Tattoo # (if available):

31. Date of rabies vaccination (MM/DD/YY) - submit copy of rabies
vaccination certificate:

Public reporting burden of this collection of information is estimated to average 45 minutes 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. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless
it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74,
Atlanta, Georgia 30329; ATTN: PRA 0920-0134.

SECTION D – ENTRY AND FINAL DESTINATION
32. Date of entry (MM/DD/YY) for intended importation
into the United States:

33. U.S. port of entry for intended importation
(refer to www.cbp.gov/contact/ports):

Intended final destination (i.e., proposed confinement location):
(Refer to the box above Section G for information about confinement)
34. Street Address:

35. Phone:

36. City:

37. State:

38. Zip Code:

SECTION E – TRAVEL ITINERARY
39. Air

A
 irline
Flight #
AWB #

r Hand carry
r Checked baggage
r Cargo

r Bus Company
r Train Company

40. Land border crossing

41. Sea

r
 P
 rivate vehicle license plate #
License plate issued by

Ship Company
Vessel name

SECTION F – REQUEST DETAILS
42. Purpose for which the dog is being imported:
r Resale r Rescue/Adoption r Personal Pet

r Research

r Veterinary Care

r Other

43. The reason why permission to import is being requested:
r Unable to vaccinate against rabies because of research protocols (attach protocols and other supporting documents)
r Dog too young to be vaccinated (i.e., younger than 3 months old)
r Less than 30 days after initial rabies vaccination
r Current rabies vaccine certificate has expired
r Other

SECTION G – SIGNATURE
I am the owner (or authorized agent for the owner) of the dog listed on this form. I understand that ownership of the dog cannot be transferred to another person while in confinement. The dog must be confined at the address listed on this form and may not be placed at any
other location or with any other person until the confinement period has ended.
I certify that the information given in this application is complete and true to the best of my knowledge.
I agree to obey the conditions listed in this application. I will comply with all restrictions and precautions in the permit, as well as all
applicable import regulations.
I understand that I may be convicted of a crime if I don’t comply with these import requirements. I could be sentenced to 1 year in jail
and/or a maximum fine of $100,000 if the violation doesn’t result in a death or a maximum fine of $250,000 if the violation does result in a
death. Violations by an organization are punishable by a maximum fine of $200,000 per violation (if no death) and $500,000 per violation
if there is a death. These penalties are provided for under 42 U.S.C. § 264 and 42 U.S.C. § 271 (as enhanced by 18 U.S.C. §§3559 & 3571).
44.

Legal Signature: Typed First and Last Name


45. Date Signed:

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of
Acceptance.

First Name:

Middle Initial:

Last Name:

Date Signed: