Form 17-8 Agreement of Pet Bird Owner

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 0579-0040. The time required to complete this information collection is estimated to average .5 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.

FORM APPROVED
OMB NO.
0579-0040

1. NAME AND ADDRESS OF OWNER (Include Zip Code)

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

STREET

AGREEMENT OF PET BIRD OWNER
INSTRUCTIONS: Complete items 1 through 6 and the applicable agreement A, B,or C.
Distribute copies as identified.
2. PASSPORT NO. (if none, give Social
Security No., or Driver's License No.)

CITY AND STATE

ZIP CODE

4. NO. OF BIRDS

5. KIND OF PET BIRDS

3. DATE OFFERED FOR ENTRY

6. FROM (Country of Origin)

7. OWNER'S AGREEMENT - SIGN A - B - C - OR D BELOW (Refusal to sign this form, automatically places option D into effect.)

A

I do hereby declare that the pet birds identified above will be maintained in my personal possession, separate and apart from all other birds and poultry at the
location indicated in item (1) below for a minimum of 30 days until released by an inspector of the Animal and Plant Health Inspection Service of the United
States Department of Agriculture. If the birds must be moved, I agree to contact the official in item (2) below prior to such movement.
I hereby agree the bird(s) will be available for inspection during the aforemen tioned period of confinement at the address in item (1) below and at such times as
deemed necessary by an inspector of the Animal and Plant Health Inspection Service of the United States Department of Agriculture. I further agree to
immediately notify the Federal Official in item (2) below if any signs of disease are noted or if the bird(s) die during the confinement period.
I understand if a laboratory specimen is taken and if found to contain the viruses of Newcastle disease or Avian Influenza that the birds will be disposed of by
the Animal and Plant Health Inspection Service of the United States Department of Agriculture.
(1) LOCATION WHERE BIRDS WILL BE HELD

(2) NAME AND ADDRESS OF FEDERAL OFFICIAL TO CONTACT

STATE

PHONE NUMBER (include Area Code)
REFERRAL NO.

LABORATORY SPECIMEN TAKEN
SPECIMENTS SUBMITTED BY (Name)

B

SIGNATURE OF OWNER

DATE

Section B applicable to Canadian pet birds.
I certify that the birds have been in my possession for at least 90 days, that they are apparently healthy, and that they have not been exposed toany other
birds during those 90 days.
SIGNATURE OF OWNER

OWNER'S TELEPHONE NO.

DATE

AREA CODE PHONE NO.
WITNESSED BY (Signature)

C

TITLE

DATE

In lieu of A above. I agree to export my birds to (Country)______________________________________________________________________________ __
SIGNATURE OF OWNER

D

DATE

In lieu of any of the above options, I hereby abandon my bird(s) to the Animal and Plant Health Inspection Service vice of the United States Department of
Agriculture for disposal.
SIGNATURE OF OWNER

DATE

8. PORT OF ENTRY

9. CARRIER AND FLIGHT NO.

10. POST-ENTRY NO.

11. DETAINING OFFICIAL (Signature)

12. TITLE

13. AGENCY

14. DATE

I certify that I have, this day, inspected the birds identified above offered for importation, and have found them to be free of evidence of communicable dise ase or exposure
thereto, and release them for the purpose as stated above.
15. PORT RELEASING OFFICIAL (Signature)

16. TITLE

17. DATE RELEASED

I have inspected the birds, inspected above, and find that all applicable provi sions of 9 CFR Part 92 as amended have been met.
18. FINAL RELEASEING OFFICIAL (Signature)

VS FORM 17-8
(MAR 2007)

19. TITLE

Previous edition may be used

20. DATE RELEASED

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 0579-0040. The time required to complete this information collection is estimated to average .05 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.

FORM APPROVED
OMB NO.
0579-0040

1. NAME AND ADDRESS OF OWNER (Include Zip Code)

UNTIED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

STREET

AGREEMENT OF PET BIRD OWNER
INSTRUCTIONS: Complete items 1 through 6 and the applicable agreement A, B,or
C. Distribute copies as identified.
2. PASSPORT NO. (if none, give Social
Security No., or Driver's License No.)

CITY AND STATE

ZIP CODE

4. NO. OF BIRDS

5. KIND OF PET BIRDS

3. DATE OFFERED FOR ENTRY

6. FROM (Country of Origin)

IMPORTED PET BIRDS BEING HELD UNDER
QUARANTINE
(1) LOCATION WHERE BIRDS WILL BE HELD

(2) NAME AND ADDRESS OF FEDERAL OFFICIAL TO CONTACT

STATE

PHONE NUMBER (include Area Code)
REFERRAL NO.

LABORATORY SPECIMEN TAKEN
SPECIMENTS SUBMITTED BY (Name)

SIGNATURE OF OWNER

STREET

H. DISEASES SUSPECTED

CITY

STATE

*MATERIAL SUBMITTED

*IDENTIFICATION

ZIP CODE

DATE

I. EXAMINATIONS REQUESTED

*SPECIES

*AGE
YRS.
MOS

*SEX

*PRESERVATION
(Fresh, Frozen, Formalin, Borax, etc.)

J. ADDITIONAL DATA (History, Clinical Signs, Post Mortem findings, remarks, etc. or State and Country of destination if animals are to be Shipped Use additional sheets 5 copies if necessary)

SIGNATURE OF SUBMITTER

LABORATORY USE ONLY
K. DATE RECEIVED

VS FORM 17-8
(MAR 2007)

L. ACCESSION NO.

M. CONDITION

N. PRIORITY

Previous edition may be used

O. DISTRIBUTION

P. RECEIVED BY

COPY DESIGNATIONS
PART 1 - STATE OF DESTINATION

PART 2 - LABORATORY (SUBMIT WITH SPECIMEN)

PART 3 - OWNER

PART 4 - PORT OF ENTRY

PRIVACY ACT NOTICE

This information is provided pursuant to Public Law 95-3579 (Privacy Act of 1974) December 31, 1974, for individuals completing the VS 1-36A.
Purpose and Use:
U.S. Code, Title 5, Section 3301 - this is what is on the current 1-36A 7 U.S.C. & 8309, 21 U.S.C. 113a.
Routine Uses:
The purpose of this form is to apply for veterinary accreditation by the Animal and Plant Health Inspection Service, U.S. Department of Agriculture.

This information will be used for (1) Referral to State Animal Health officials to certify accreditation status. (2) Referral to State veterinary examining
boards to certify accreditation status. (3) Referral to the appropriate agency, whether Federal, State, local, or foreign, charged with the responsibility of
investigating or prosecuting a violation of law, or of enforcing or implementing the statute, rule, regulation or order issued pursuant thereto, of any
record within this system when information available indicates a violation or potential violation of law, whether civil, criminal or regulatory in nature, and
whether arising by general statute or particular program statute, or by rule, regulation, or order issued pursuant thereto. (4) Disclosure to the
Department of Justice if they agree to represent the employee, or the United States, where the agency determines that litigation is likely to affect the
agency or any of its components, is a party to litigation or has an interest in such litigation, and the use of such records by the Department of Justice is
deemed by the agency to be relevant and necessary to the litigation; provided, however, that in each case, the agency determines that disclosure of
the records to the Department of Justice is a use of the information contained in the records that is compatible with the purpose for which the records
were collected.
(5) Disclosure in a proceeding before a court or adjudicative body before which the agency is authorized to appear, when the agency, or any
component thereof, or any employee of the agency in his or her official capacity, or any employee of the agency in his or her individual capacity where
the agency has agreed to represent the employee, or the United States, where the agency determines that litigation is likely to affect the agency or any
of its components, is a party to litigation or has an interest in such litigation, and the agency determines that use of such records is relevant and
necessary to the litigation; provided, however, that in each case, the agency determines that disclosure of the records to the court is a use of the
information contained in the records that is compatible with the purpose for which the records were collected. (6) Disclosure may be made to a
congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual.
(7) To periodically disseminate information and solicit feedback from accredited veterinarians within the system on proposed Federal programs for the
purpose of educating and involving the accredited veterinarians in current program development, program requirements, and standards of conduct.
(8) Disclosure to the public for the purpose of locating and contacting accredited veterinarians for a specific geographical location. (9) To contact
accredited
veterinarians
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emergency
response
effortsmay
to contain
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of or
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it may result
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not being processed. The social security number and birth date will be used to create a unique identifier.