FORM APPROVED
CONTINUATION PAGE FOR APPLICATION FOR PERMIT TO
OMB NO. 0920-0199
U.S. DEPARTMENT OF
IMPORT INFECTIOUS BIOLOGICAL AGENTS INTO THE
EXP DATE 01/31/2017
HEALTH & HUMAN SERVICES
Public Health Service
UNITED STATES
Continuation Page
of
continuation pages
SECTION A continuation (Other Persons Authorized to use Permit)
Permittee #2
1. Permittee’s Last Name
2. First Name
3. MI
4. Permittee’s Organization
5. Physical Address
6. City
7. State
8. Zip Code
(NOT a post office box)
9. Permittee’s Telephone Number
10. Permittee’s Fax Number
11. Permittee’s Email
12. Secondary Contact’s Name
13. Secondary Contact’s Telephone Number
14. Secondary Contact’s Email
15. Will this individual be hand carrying the imported biological agent?
Yes
No
Permittee #3
1. Permittee’s Last Name
2. First Name
3. MI
4. Permittee’s Organization
5. Physical Address
6. City
7. State
8. Zip Code
(NOT a post office box)
9. Permittee’s Telephone Number
10. Permittee’s Fax Number
11. Permittee’s Email
12. Secondary Contact’s Name
13. Secondary Contact’s Telephone Number
14. Secondary Contact’s Email
15. Will this individual be hand carrying the imported biological agent?
Yes
No
Permittee #4
1. Permittee’s Last Name
2. First Name
3. MI
4. Permittee’s Organization
5. Physical Address
6. City
7. State
8. Zip Code
(NOT a post office box)
9. Permittee’s Telephone Number
10. Permittee’s Fax Number
11. Permittee’s Email
12. Secondary Contact’s Name
13. Secondary Contact’s Telephone Number
14. Secondary Contact’s Email
15. Will this individual be hand carrying the imported biological agent?
Yes
No
Permittee #5
1. Permittee’s Last Name
2. First Name
3. MI
4. Permittee’s Organization
5. Physical Address
6. City
7. State
8. Zip Code
(NOT a post office box)
9. Permittee’s Telephone Number
10. Permittee’s Fax Number
11. Permittee’s Email
12. Secondary Contact’s Name
13. Secondary Contact’s Telephone Number
14. Secondary Contact’s Email
15. Will this individual be hand carrying the imported biological agent?
Yes
No
CDC Form 0.753 (Continuation), Revised January 2014