Aphis Form 2007 - Contact And Qualifications Of Veterinary Biologics Personnel - United States Department Of Agriculture

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UNITED STATES DEPARTMENT OF AGRICULTURE
OMB Approved
This report is required by regulations (9 CFR 102.4 and 114.7). Failure to report can result in suspension or
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
0579-0013
revocation of establishment license.
(See instructions on reverse side for additional instructions)
VETERINARY SERVICES
EXP. 03/2018
CENTER FOR VETERINARY BIOLOGICS
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond
CONTACT AND QUALIFICATIONS
to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information is
0579-0013. The time required to complete this information collection is estimated to average 0.2 hours per response, including the
OF VETERINARY BIOLOGICS PERSONNEL
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information.
1. EMPLOYEE CONTACT INFORMATION
(Print information in area requested.)
(include applicable suffix)
[A] TITLE
[B] LAST NAME,
FIRST NAME
MIDDLE
[C] ESTABLISHMENT NAME
(Dr., Mr., Ms.)
INITIAL
[E] TELEPHONE NUMBER
[D] ESTABLISHMENT
[F] ADDRESS OF YOUR PRIMARY WORK SITE
LICENSE NUMBER
[G] EMAIL (Recommended)
2. EMPLOYEE ROLE AT ESTABLISHMENT
(use additional lines, if necessary.)
[A] TITLE OF POSITION HELD
[C]
DATE OF PREVIOUS
APHIS FORM 2007 ON
FILE FOR EMPLOYEE
(mm/dd/yyyy)
[B] FUNCTION(S) OR DUTIES
☐
NEW FORM 2007
CHECK THIS BOX IF THERE IS
NO PREVIOUS FORM 2007 ON
FILE FOR EMPLOYEE
AT THIS ESTABLISHMENT.
3. EMPLOYEE EDUCATION
[A] NAME OF SCHOOL, UNIVERSITY OR INSTITUTION
[B] TYPE OF DEGREE OR CERTIFICATION
[C] DATE ATTAINED (mm/dd/yyyy)
4. SIGNATURE OF EMPLOYEE AND DATE SIGNED (mm/dd/yyyy)
SIGNATURE IN BLOCK 5.
CERTIFIES SUBMITTED FORM
(See Privacy Act Notice at bottom of instructions.)
--------------------------------------------------------------------------------------DATE-----------------------------
5. [A] CERTIFICATION SIGNATURE (Liaison or Alternate Liaison)
[B] SIGNATORY TITLE
[C] DATE CERTIFIED
(
mm/dd/yyyy)
I certify that this person is competent by training, education, and experience, and has demonstrated
fitness abilities as listed, in the Functions Block 2., to produce such products in compliance with the
☐
Act.
LIAISON
☐
ALTERNATE LIAISON
-----------------------------------------------------------------------------------------------------------------------------------
6. APHIS USE ONLY: Receipt Identification Block
DATE CONTROL AREA
APHIS FORM 2007
(Previous editions are obsolete.)
APR 2015

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