Vs Form 16-3 - Application For Permit To Import Or Transport Controlled Material Or Organisms Or Vectors

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PLEASE TYPE OR PRINT CLEARLY

controlled

material,

organisms

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of

The valid OMB control

vectors may be imported or moved

information unless it displays a valid OMB control number.

The time required to complete this information

number for this information

interstate unless the data requested on

collection is estimated to average .0166 hours per response, including the time for reviewing instructions,

collection is 0579-0015,

this form is furnished and certified (9 CFR

searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the

0094, 0183, 0213, and 0245.

94, 95, and 122).

collection of information.

U.S. DEPARTMENT OF AGRICULTURE

1. MODE OF TRANSPORTATION (Please "X"):

ANIMAL AND PLANT HEALTH INSPECTION SERVICE

VETERINARY SERVICES

AIR

SEA

LAND

ANY

National Center for Import-Export, Products Program

4700 River Road, Unit 40

Riverdale, MD 20737-1231

2. U.S. PORTS OF ENTRY

APPLICATION FOR PERMIT TO:

IMPORT OR TRANSPORT CONTROLLED MATERIAL OR

ORGANISMS OR VECTORS

4. SHIPPER(s): (Name and Address of producer/shipper)

3. IMPORTER (Name, organization, complete address, telephone and fax

number of individual who will receive and be responsible for the imported material)

5. DESCRIBE THE MATERIAL TO BE IMPORTED (Provide the following information, as applicable: Animal species and tissue of origin of animal product, country of origin of the

animals from which the raw animal product was sourced, processing country, recombinant system and genetic inserts, antibody immunogens, stabilizers, nutritive factors of animal

origin in media.) (COMPLETE VS FORM 16-7 for cell cultures and their products.)

6. QUANTITY, FREQUENCY OF IMPORTATION, AND EXPECTED COMPLETION DATE (estimate)

7. PROPOSED USE OF MATERIAL AND DERIVATIVES (Also, for animal pathogens or vectors, describe facilities/biosafety procedures)

8. IF FOR USE IN ANIMALS, SPECIFY THE ANIMAL SPECIES

9. TREATMENT OF MATERIAL PRIOR TO IMPORTATION INTO THE U.S. (Processing/purification methods, including time at specific temperatures, pH, other treatments, disease

safeguards, etc.)

10. METHOD OF FINAL DISPOSITION OF IMPORTED MATERIAL AND DERIVATIVES

I CERTIFY AS AUTHORIZED BY THE COMPANY/INSTITUTION THAT I REPRESENT, THAT THIS MATERIAL WILL BE USED IN ACCORDANCE WITH ALL RESTRICTIONS

AND PRECAUTIONS AS MAY BE SPECIFIED IN THE PERMIT.

11. SIGNATURE OF APPLICANT

12. TYPED NAME AND TITLE

13. DATE

14. APHIS USER FEE CREDIT ACCOUNT NO. OR METHOD OF USER FEE

PAYMENT (for VISA or Mastercard include number and expiration date).

VS FORM 16-3 (NOV 99)

Clear Form