Form VS 16-3 VS 16-3 Diagnostic Specimen Application

PLEASE TYPE OR PRINT CLEARLY

Failure to supply all applicable information can delay the processing of this application.
No controlled material, organisms or
vectors may be imported or moved
interstate unless the data requested on this
form is furnished and certified (9 CFR 94,
95, and 122).

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 time required to complete this information
collection is estimated to average .0166 hours per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information.

U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
National Center for Import-Export, Products Program
4700 River Road, Unit 40
Riverdale, MD 20737-1231

The valid OMB control
numbers for this information
collection is 0579-0015,
0094, 0183, 0213, and 0245.

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

AIR

SEA

LAND

ANY

2. U.S. PORTS OF ENTRY

APPLICATION FOR PERMIT TO:
IMPORT OR TRANSPORT CONTROLLED MATERIAL OR
ORGANISMS OR VECTORS
3. IMPORTER (Name, organization, complete address, telephone and fax
number of individual who will receive and be responsible for the imported mater ial)

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

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, reco mbinant 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 procedur es)

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)