Usda - Aphis Application For Credit Account

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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control

number. The valid OMB control number for this information collection is 0579-0055. The time required to complete this information collection is estimated to

FORM APPROVED

average .25 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and

OMB NO. 0579-0055

completing and reviewing the collection of information.

USDA - APHIS

APPLICATION FOR CREDIT ACCOUNT

1. ACCOUNT TYPE (check applicable block(s))

Veterinary Services User Fee

Plant Protection and Quarantine Reimbursable Overtime

Other Services (please specify):______________________________

2. APPLICANT NAME AND TITLE

3. FIRM NAME

4. DATE BUSINESS STARTED

5. BILLING ADDRESS

6. PHYSICAL LOCATION ADDRESS

7. TELEPHONE NUMBER

8. FAX NUMBER

9. ACCOUNT CONTACT NAME(S)

10. LIST FULL NAME,TITLE, HOME ADDRESS, AND TELEPHONE NUMBER FOR EACH PRINCIPAL OFFICER AND/OR OWNER

11. LIST OTHER TRADE NAMES, SUBSIDIARIES, BRANCHES, DIVISIONS, PARENTS, ETC.

12. ORGANIZATION TYPE

Individual

Partnership

Corporation

College or University

State Gov't

Federal Gov't Agency

Other (specify)

13. NUMBER OF EMPLOYEES

14. DO YOU OWN

YES

OR RENT YOUR BUILDING

YES

IF RENTING, FROM WHOM:

Name

Telephone Number

15. IRS TAX IDENTIFICATION NO. OR APPLICANT'S SOCIAL SECURITY NO. (If either is not provided, credit will not be issued)

TAX IDENTIFICATION NUMBER:

SOCIAL SECURITY NUMBER:

16. FORMER BUSINESS LOCATION(S) FOR THE PAST SEVEN YEARS

PRIVACY ACT STATEMENT

Section 552 of Title 5 to the U.S. Code authorizes collection of this information. The primary use of this information is to gather data that will be used to establish

a credit account for the purchase of goods and services from the Animal and Plant Health Inspection Service. User fees are authorized by Section 2509 (c) (1)

of the Food, Agriculture, Conservation and Trade Act of 1990, amended by the Omnibus Budget Reconciliation Act of 1990, referred to as the 1990 Farm Bill,

(21 U.S.C. 136 and 136a and 21 U.S.C. 135). Information collected will be used by Federal employees who have a need for the information in the performance

of their official duties. Additional disclosures of this information may be made to Federal, State, local, or foreign agencies in relation to investigations of civil,

criminal, or regulatory investigations or prosecutions, to the court of competent jurisdiction, to the United States Department of Agriculture's office of Inspector

General's Office in connection with user fees reviews, and to consumer reporting agencies in accordance with Section 3711 (f) of Title 31.

Your social security account number is solicited under the authority of the Internal Revenue Code (26 U.S.C. 6011 (b) and 6109) and Executive Order 9397,

November 22, 1943, for use as a taxpayer and/or employee identification number. Disclosure of your social security number and other requested information is

voluntary; however, failure to provide the information may result in disapproval of your request for credit.

APHIS FORM 192

Previous editions are obsolete.

JAN 2002