Form Ai-473- Application And Agreement For Participation printable pdf download

Form Ai-473- Application And Agreement For Participation

AI-473 (REV 12/09)

STATE OF NEW YORK

DEPARTMENT OF AGRICULTURE AND MARKETS

DIVISION OF ANIMAL INDUSTRY

10B AIRLINE DRIVE

ALBANY, NY 12235

APPLICATION AND AGREEMENT FOR PARTICIPATION

IN THE

NYS DEPARTMENT OF AGRICULTURE AND MARKETS

PULLORUM-TYPHOID CONTROL AND ERADICATION PROGRAM

It shall be understood by the person entering into this agreement that the State of New York shall not be held responsible for

damage of any sort, kind or description resulting out of the execution of this agreement. The agreement shall be deemed

executory only to the extent of the money available.

I hereby request that my flock(s) and/or hatchery described in this application be accepted for the control and eradication

of pullorum-typhoid disease and the required blood tests and other necessary inspection to be carried out by an official

agent in compliance with the program Rules and Regulations set forth in Parts 145 and 147 of Volume 9 of the Code of

Federal Regulations. (Rules and Regulations may be obtained from the Department of Agriculture and Markets on

request).

Please review information below and make any necessary changes. Fill in the blanks marked by asterisk(***).

NPIP

Federal

New Applicant? Yes ___

No ___

Approval #.____________

Identification (PIN) #___________________

Flock Owner _____________________________________________Farm Name______________________________

Flock Address ____________________________________________________________________________________

City ___________________________________________

State ___________________

Zip __________________

Phone (_______) _______________________________

County__________________________________________

***E-Mail Address _______________________________________________________

***Desired Test Date______________________________*** Flock size _______________________________________

I AGREE:

1. To blood test up to 300 poultry on the premises more than four months of age and to identify all birds

in a manner that is acceptable to the state agency.

2. To allow on my premises, or in my hatchery only poultry or poultry products having a New York State

Pullorum-Typhoid Clean Flock Classification or its equivalent.

3. To supply the necessary assistance to the official agency in carrying out the required testing and

inspections.

4. To isolate all reactors and retest in 30 days or submit up to five reactors for bacteriological exam.

_______________________________________________

____________________________

SIGNATURE

DATE

Form Ai-473- Application And Agreement For Participation

Related Articles

Related forms

Related Categories