Form VS 1-63 VS 1-63 NAIS Tribal Premises Registration System Implementation

National Animal Identification System (NAIS)

Tribal Premises Registration System Implementation Request

TRIBE ________________________________________

Who will function as NAIS Administrator for the tribe?

This person is responsible for coordinating the NAIS activities for the tribe including outreach, education, premises data collection, premises registration, and premises contact information updates. The NAIS Administrator has the access level to perform all data administration functions for the tribe including data entry, data editing, data viewing, data searching, account and premises creation and inactivation, creating new users and contacts and assigning of access privileges. This is the person with whom USDA communicates on premises registration issues.

NAME _________________________________________________________________

ADDRESS______________________________________________________________

CITY/STATE ______________________________________ ZIP__________________

PHONE ____________________ FAX _________________________

EMAIL__________________________________

After reading the list of options, decide how your tribe would like to participate. Not every tribe needs to submit a request at this time. Submit this request form only when your tribe is ready to proceed with premises registration.

Please indicate your request by checking one of the boxes below.

• Our tribe would like to implement the Tribal Premises Registration System funded by USDA. We have a dedicated database administrator and sufficient personnel for data entry and premises exception requirements.

• Our tribe would like to implement the Tribal Premises Registration System funded by USDA. We do not have a dedicated database administrator or sufficient personnel for data entry. We would like to use the following organization/company to provide these resources as an Authorized Agent of our tribe.

Organization Name:

_____________________________________________________________

• Our tribe would like to use the Standardized Premises Registration System funded by USDA that is used by the State in which the tribe is located. We will work with the State to register our premises.

VS Form 1-63

June 2007

• Our tribe would like to utilize a premises registration system we have developed for ourselves with our own resources (not Federal funds). We request that USDA evaluate our system to ensure that it is compliant with the standards of the NAIS. If our system meets the standards, we further request that USDA provide interfaces to the National Premises Number Allocator and the National Premises Information Repository.

• Our tribe would like to utilize the premises registration system provided by a private company with which we have a memorandum of understanding or contract using our own resources (not Federal funds). We request that USDA evaluate this system to ensure that it is compliant with the standards of the NAIS. If the system meets the standards, we further request that USDA provide interfaces to the National Premises Number Allocator and the National Premises Information Repository.

Company Name:

__________________________________________________________________

Please send this request form and address any questions or comments to:

John F. Wiemers Phone: (309) 344-1942

USDA, APHIS, VS Fax: (309) 344-1489

2100 S. Lake Storey Rd. [email protected]

Galesburg, IL 61401

Certification of Authorized Tribal Representative: I hereby certify that this request is authorized according to the laws governing our tribe.

NAME: ______________________________ _________________________________

TITLE: ______________________________ __________________________________

SIGNATURE ____________________________________________________________

DATE _____________________________ PHONE ___________________________

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-XXXX. The time required to complete this information collection is estimated to average 1 hour 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.

VS Form 1-63

June 2007

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