vs 17-65C Post Entry Quarantine Record of Zoo Animals

According to the Paperwork Reduction Act of 1995, no persons are required to re spond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information col lection is 0579-0040. The time required to complete
this information collection is estimated to average .190 hours per response, in cluding the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completin g and reviewing the collection of information.

No zoo animals can be released from quarantine for movement to an
approved zoological park unless this form is completed at the New York
Port of Entry (9 CFR 93).
FORM APPROVED: OMB NO 0579-0040

1. VS FORM 17-30 NO.

U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

2. PERMIT NO.

POST ENTRY QUARANTINE RECORD OF ZOO ANIMALS
3. COUNTRY OF ORIGIN

NOTE: Health Inspection on Reverse
INSTRUCTIONS: Insert carbons and complete all entries by typewriter or ink. Signatures in ink only. VS
Quarantine Station-Complete items 1 through 16 on all copies. Send yellow to Riverdale. Send pink, green
and white to Zoo. Zoo Official-Complete items 17 through 19 on all copies, send green and white to VS
Field Station, retain pink. VS Field Station-Retain green and send white to Riverdale, MD office.
5. TATTOO

6. SPECIES (Description)

7. SEX

10. IMPORTER (Name and address include Zip Code)

15. DESTINATION - APPROVED ZOO (Name and address
include Zip Code)

4. PORT OF EMBARKATION

8. ESTIMATED YEAR
OF BIRTH

9. CARRIER

11. PORT OF ENTRY

12. DATE OF ENTRY

13. TERMINATION DATE OF
QUARANTINE

14. DATE REMOVED FROM
QUARANTINE STATION

FOR USE BY VS RIVERDALE, MD OFFICE - Record of Transfer
20. APPROVED ZOO (Name and address include Zip
Code)

25. APPROVED ZOO (Name and address include Zip
Code)

16. ENDORSEMENT

21. ENDORSEMENT

26. ENDORSEMENT

17. DATE OF ARRIVAL AT ZOO

22. DATE OF ARRIVAL AT ZOO

27. DATE OF ARRIVAL AT ZOO

18. SIGNATURE OF RESPONSIBLE OFFICIAL

23. SIGNATURE OF RESPONSIBLE OFFICIAL

28. SIGNATURE OF RESPONSIBLE OFFICIAL

19. LOCATION IN PARK

24. LOCATION IN PARK

29. LOCATION IN PARK

DATE

VS FORM 17-65C
(OCT 2005)

PEN NO.

DATE

PEN NO.

(Previous editions may be used)

DATE

PEN NO.

PERIODIC HEALTH INSPECTION
(Inspections to be made at least every six months - type data, sign in ink)
DATE

VS FORM 17-65C (Reverse)

REMARKS

SIGNATURE
(Examining Veterinarian)

COPY DESIGNATIONS
LOWER RIGHT CORNER
IN BLACK INK

PART 1 - AREA OFFICE, RIVERDALE, MD

PART 2 - ZOO

PART 3 - RIVERDALE, MD OFFICE

PART 4 - VS AREA OFFICE