VS 4-10 NVSL Contact Information Update

National Veterinary Services Laboratories Request Forms

VS 4-10 JUN 2024-ICR (20240603) - NSC

State

OMB: 0579-0430

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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 0579-0430. 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

0579-0430

Exp. 02/2025

United States Department of Agriculture

Animal and Plant Health Inspection Service

Veterinary Services

NVSL Contact Information Update

Name of Business/Laboratory (Required):


Business type:


Address 1:


Address 2:


City:


State/Province:


Postal Code:

Country:


Business Phone Number (Required):


Business Fax Number (Optional):

Business Premises ID:


Business Email Address(s) (To be included in all reports associated with this business):


Individuals Authorized to Submit and Incur Expenses Under this Business (Select Individual and Enter Contact Information)

Individual: Veterinarian Biologist Animal Health Technician Other (Specify)

Salutation:


First Name:

Middle Name:


Last Name:


Individual Email Address(s) (To be included in all reports submitted):

Phone Number:

National Veterinary Accreditation Number (Optional):

Individual: Veterinarian Biologist Animal Health Technician Other (Specify)

Salutation:


First Name:

Middle Name:


Last Name:


Individual Email Address(s) (To be included in all reports submitted):


Phone Number:

National Veterinary Accreditation Number (Optional):

Individual: Veterinarian Biologist Animal Health Technician Other (Specify)

Salutation:


First Name:

Middle Name:


Last Name:


Individual Email Address(s) (To be included in all reports submitted):


Phone Number:

National Veterinary Accreditation Number (Optional):

Individual: Veterinarian Biologist Animal Health Technician Other (Specify)

Salutation:


First Name:

Middle Name:


Last Name:


Individual Email Address(s) (To be included in all reports submitted):


Phone Number:

National Veterinary Accreditation Number (Optional):

Individual: Veterinarian Biologist Animal Health Technician Other (Specify)

Salutation:


First Name:

Middle Name:


Last Name:


Individual Email Address(s) (To be included in all reports submitted):


Phone Number:

National Veterinary Accreditation Number (Optional):

Comments/Additional Instructions:


This record is no longer needed; remove it from your active files.

Return updated forms via one of the following ways:

Email: NVSL.info@usda.gov
Fax Number: 515-337-7022

Mail: USDA/APHIS/VS/National Veterinary Services Laboratories | Attn: LIMS Contact Update | 1920 Dayton Ave. | Ames, IA 50010

VS FORM 4-10
JUN 2024

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