General Permit Ppq Form 526 - Aphis Us Department Of Agriculture Page 3

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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 numbers

OMB APPROVED:

for this information collection are 0579-0049, 0054, 0207, and 0213. The time required to complete this information

0579-0049, 0054,

collection is estimated to average .17 hours per response, including the time for reviewing instructions, searching existing

0207, and 0213

data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

UNITED STATES DEPARTMENT OF AGRICULTURE

SECTION A – TO BE COMPLETED BY THE APPLICANT

ANIMAL AND PLANT HEALTH INSPECTION SERVICE

NAME, TITLE, AND ADDRESS (Include ZIP Code

PLANT PROTECTION AND QUARANTINE

APPLICATION FOR PERMIT TO MOVE

LIVE PLANT PESTS, NOXIOUS WEEDS,

SOIL, AND PROHIBITED PLANTS

3. TYPE OF PEST TO BE MOVED

Pathogens

Arthropods

Noxious Weeds

Other (Specify) U.S. EPA Registered Biopesticides

This permit does not authorize the introduction, importation, interstate

2. TELEPHONE NO.

movement, or release into the environment of any genetically

engineered organisms or products.

B. CLASSIFICATION

LIFE

NO. OF

F. ARE PESTS

SCIENTIFIC NAMES OF

(Orders, Families,

STATES, IF

SPECIMENS OR

SHIPPED FROM

ESTABLISHED

MAJOR HOST(S)

PEST TO BE MOVED

Races, or Strains)

APPLICABLE

UNITS

(Country or State)

IN U.S.?

OF THE PEST

N/A

7. WHAT HOST MATERIAL OR SUBSTITUTES WILL ACCOMPANY WHICH PESTS (Indicate by line number)

N/A

8. DESTINATION

9. PORT OF ARRIVAL

10. APPROXIMATE DATE OF ARRIVAL OR

N/A

INTERSTATE MOVEMENT

13. METHOD OF SHIPMENT

11. NO. OF SHIPMENTS

12. SUPPLIER

N/A

Air Mail

Air Freight

Baggage

Auto

14. INTENDED USE (Be specific, attach outline of intended research.)

N/A

15. METHODS TO BE USED TO PREVENT PLANT PEST ESCAPE

16. METHOD OF FINAL DISPOSITION

N/A

17.

SIGNATURE OF APPLICANT (Must be person named in Item 1.)

18. DATE

Applicant must be a resident of the U.S.A.

I/We agree to comply with the safeguards printed on the reverse of

Activation of [Submit Application] function

N/A

this form, and understand that a permit may be subject to other

conditions specified in Sections B and C.

Warning: Any alteration, forgery, or unauthorized use of this document is subject to civil penalties of up to $250,000 (7 U.S.C. 7734(b)) or punishable by a fine of not

more than $10,000, or imprisonment of not more than 5 years, or both (18 U.S.C. 1001)

SECTION B – TO BE COMPLETED BY STATE OFFICIAL

19. RECOMMENDATION

20. CONDITIONS RECOMMENDED

Concur

(Approve)

Comments

N/A

(Disapprove)

(Accept USDA Decision)

21. SIGNATURE

22. TITLE

23. STATE

24. DATE

N/A – no State review required

N/A

SECTION C – TO BE COMPLETED BY FEDERAL OFFICIAL

25. PERMIT NO.

PERMIT

(Permit not valid unless signed by an authorized official of the U.S. Department of Agriculture, Animal and Plant Health Inspection Service.)

Under authority of the Plant Protection Act of 2000, permission is hereby granted to the applicant named above to move pests described, except as deleted, subject to conditions

stated on or attached to this application. (See standard conditions on reverse side.)

* For exotic plant pathogens, attach a completed PPQ Form 526-1 (Live Plant Pathogens).

26. SIGNATURE OF PLANT PROTECTION AND QUARANTINE OFFICIAL

27. DATE

28. LABELS ISSUED

29 VALID UNTIL

30. PEST CATEGORY

General Permit – PPB issuer signature

3 YEARS FROM

BIOCONTROL/

N/A

ISSUANCE