APHIS Form 2020 Shipment 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 .33 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.

This report is required by Regulation (9 CFR 113).
Failure to report can result in no certification being
made for authenticity of samples of product.

1. DATE SUBMITTED
U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE

SHIPMENT AND RECEIPT OF BIOLOGICS SAMPLES

OMB Approved
0579-0013
EXP. XX/XXXX

2. FIRM LICENSE NO.

3. NAME AND MAILING ADDRESS OF FIRM (Include Zip Code)

INSTRUCTIONS: Submit original and one copy with samples. (Leave carbons intact.)
4. PURPOSE
ROUTINE CONCURRENT SAMPLE

MASTER SEED

CELL LINE

RESUBMISSION (Specify in remarks)

RETENTION SAMPLE

PRELICENSING SAMPLE

OTHER (Specify in remarks)
OTHER (Specify)

5. HOW IS PRODUCT SHIPPED
DRY ICE

REFRIGERATED
PRODUCT NAME (No trade names)
(Only one entry per line)
6.

PRODUCT
CODE

SERIAL
NO.

SAMPLE
CODE
(For Goverment Use Only)

NO.

7.

8.

9.

10.

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.
14. SIGNATURE OF AUTHORIZED GOVERNMENT SAMPLER

PRODUCT IS SHIPPED VIA

UNREFRIGERATED
SAMPLE CONTAINERS SUBMITTED

16. REMARKS

15. DATE

TELEPHONE NUMBER

ACKNOWLEDGEMENT OF RECEIPT OF SAMPLES
17. CONDITION AND REMARKS

18. RECEIVED BY (Signature)

19. DATE RECEIVED

APHIS FORM 2020
APR 2015

SIZE

FIELD
DOSE

INDICATE
BULK
OR FINAL

11.

12.

13.