VS 9-22 Application for U.S. Avian Influenza and Newcastle Disea

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 0579-0007 and 0579-XXXX. 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 maintaining the data needed, and completing
and reviewing the collection of information.

OMB Approved
0579-0007 and XXXX

Application For U.S. Avian Influenza
and Newcastle Disease
Clean Compartment Component Removal
Instructions: Applicants please complete Sections A and B and certify with signature. Then send the form to the OSA
which completes Section C and signs. OSA returns form to NPIP.

A. Background Information. To be completed by company seeking removal of a component

within a certified compartment. Please note that once a component has been successfully removed, it
will no longer function as part of the compartment. Adding the component back to the compartment
will require recertification using Application Form B.

Name of Company
Company Mailing Address
Name of Contact
Telephone Number
Alternate Telephone Number
Fax Number
Email Address
NPIP Classification

U.S. AI Clean 
U.S. ND Clean 

U.S. H5/H7 AI Clean 

Breed/Type of Poultry
NPIP Classification Seeking
Compartment Mailing Address
Compartment Location (List States
Involved)
Name of Compartment
Type of Components (F, M, H, and E)
to add within Compartment

Farm  Feedmill  Hatchery  Egg Depot 

B. Reason for Removal. To be completed by company seeking component removal. To be eligible
for removal as a compartment, a justification for removal and a detailed description of how the
component removal will affect the rest of the compartment must be provided. Please use the box below.
(Note: If component removal will not affect the compartment, please check here .)

VS FORM 9-22
APR 2019

C. Verification. To be completed by each Official State Agency. Please place a check mark by the
answer that applies.

Is the component of the compartment part of a company that is a participant in
the U.S. H5/H7 Avian Influenza and Newcastle Disease Clean Compartment
program and in good standing with the NPIP: U.S. H5/H7 Avian Influenza Clean
and Newcastle Disease Clean Programs for Turkey Breeding Flocks?
Is the component of the compartment part of a company that is a participant in
the U.S. Avian Influenza and Newcastle Disease Clean Compartment program
and in good standing with the NPIP: U.S. Avian Influenza Clean and Newcastle
Disease Clean Programs for Primary Egg-Type Chicken Breeding Flocks?
Is the component of the compartment part of a company that is a participant in
the U.S. Avian Influenza and Newcastle Disease Clean Compartment program
and in good standing with the NPIP: U.S. Avian Influenza Clean and Newcastle
Disease Clean Programs for Primary Meat-Type Chicken Breeding Flocks?
Within the company, are all other operations certified as components within
the registered compartment part of the U.S. Avian Influenza and Newcastle
Disease Clean Compartment program (for egg-type chicken breeding flocks and
meat-type chicken breeding flocks) or the U.S. H5/H7 Avian Influenza and
Newcastle Disease Clean Compartment (for turkey breeding flocks) and located
in a State which has an APHIS-approved Initial State Response and Containment
Plan?

YES

NO

CERTIFICATION OF OFFICIAL STATE AGENCY or AGENCIES
I DO HEREBY CERTIFY THAT ALL STATEMENTS MADE BY ME IN THIS APPLICATION ARE TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF. FURTHER, I UNDERSTAND THAT
IN THE EVENT I HAVE KNOWINGLY AND WILLFULLY MADE ANY FALSE STATEMENTS, I WILL BE LIABLE
FOR PUNISHMENT IN ACCORDANCE WITH ALL APPLICABLE LAWS AND STATUTES.
State:

State:

Signature:

Signature:

Date:

Date:

State:

State:

Signature:

Signature:

Date:

Date:

CERTIFICATION OF APPLICANT
I DO HEREBY CERTIFY THAT ALL STATEMENTS MADE BY ME IN THIS APPLICATION ARE TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF, AND I HAVE OBTAINED ALL
NECESSARY OFFICIAL STATE AGENCIES’ CERTIFICATION IN C ABOVE. FURTHER, I UNDERSTAND THAT IN
THE EVENT I HAVE KNOWINGLY AND WILLFULLY MADE ANY FALSE STATEMENTS, I WILL BE LIABLE FOR
PUNISHMENT IN ACCORDANCE WITH ALL APPLICABLE LAWS AND STATUTES. FURTHER, I CERTIFY THAT
BY COMPLETION OF THIS FORM, THIS COMPONENT OF THE COMPARTMENT WILL HAVE TO GO
THROUGH THE RE- APPLICATION PROCESS TO BE FORMALLY RECOGNIZED AS A CERTIFIED COMPONENT.
Signature:
Date:

Application
A complete application must be sent to:
The National Poultry Improvement Plan
1506 Klondike Road,
Suite 101
USDA-APHIS-VS
Conyers, GA 30094
Denise.L.Heard@aphis.usda.gov
with cc to
Christina.Lindsey@aphis.usda.gov

For Department Use Only
Date
Received:

Reviewer:

Check Here if Approval Granted for Removal of Component: 
Check Here if Approval Denied for Removal of Component: 
Signature:
If Denied, List Reasons: