VS 17-11 Application for Quarantine Facility for Birds

FORM APPROVED OMB NO. 0579-0040
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 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 in structions, 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
APPLICATION FOR A QUARANTINE FACILITY FOR BIRDS
INSTRUCTIONS: Please type or print. Return one copy of the completed application to the ad dress
indicated at right. If you need more space to answer any of the questions, con tinue on reverse or on a
separate sheet. Cite item number.

A completed application is required for
approval of a privately-operated bird
quarantine facility. The information is used
by the USDA-APHIS to take action
concerning the requested approval
(9CFR 92).

SEND COMPLETED APPLICATION TO:

USDA-APHIS-VS
Import/Export Animals and Products Staff
4700 River Road, Unit 39
Riverdale, MD 20737

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

2. ADDRESS WHERE QUARANTINE FACILITY WILL BE LOCATED
(if different from item 1)

TELEPHONE NO. (include area code)

TELEPHONE NO. (include area code)

3. NAME, TITLE, AND ADDRESS OF INTENDED OPERATORS, PARTNERS, OFFICERS, DIRECTORS, HOLDERS OR OWNERS OF 10 PERCENT OR MORE OF
VOTING STOCK, AND EMPLOYEES IN A MANAGERIAL OR EXECUTIVE CAPACITY.
A.

NAME

B.

4. WATER SOURCE ("X" one)

Public

TITLE

C. ADDRESS (No., Street, City and Zip Code

5. WASTE DISPOSAL ("X" one or both, as applicable)

Private

Sewer

Incinerator

6. PLANS FOR PROPOSED FACILITY (Make a drawing of floor plan or attach blueprints of your facility) SHOWING LO CATION FOR:
9 CFR 92.106
•

Bird Holding area(s)

• Clothes storage and change area(s)

• Necropsy room (showing entry and refrigeration)

• Equipment storage area(s)

• Feed storage area(s)

• Entries and exits

• Washing area(s) for equipment

• Office area(s)

• Shower area(s)

• Ventilation arrangements

ALL OTHER PROVISIONS MUST BE MET AS SPECIFIED IN THE REGULATIONS

CERTIFICATION
Application is hereby made for approval of a USDA Approved Quarantine Facility for bird importations. I certify that the information provided herein is
true and correct to the best of my knowledge and belief, and agree to comply with the applicable regulations in 9 CFR Part 92.
7. SIGNATURE OF IMPORTER

VS FORM 17-11
MAY 2003

8. PRINT NAME

PREVIOUS EDITIONS ARE OBSOLETE

9. DATE

FORM APPROVED OMB NO. 0579-0040
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 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 in structions, 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
APPLICATION FOR A QUARANTINE FACILITY FOR BIRDS
INSTRUCTIONS: Please type or print. Return one copy of the completed application to the ad dress
indicated at right. If you need more space to answer any of the questions, con tinue on reverse or on a
separate sheet. Cite item number.

A completed application is required for
approval of a privately-operated bird
quarantine facility. The information is used
by the USDA-APHIS to take action
concerning the requested approval
(9CFR 92).

SEND COMPLETED APPLICATION TO:

USDA-APHIS-VS
Import/Export Animals and Products Staff
4700 River Road, Unit 39
Riverdale, MD 20737

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

2. ADDRESS WHERE QUARANTINE FACILITY WILL BE LOCATED
(if different from item 1)

TELEPHONE NO. (include area code)

TELEPHONE NO. (include area code)

3. NAME, TITLE, AND ADDRESS OF INTENDED OPERATORS, PARTNERS, OFFICERS, DIRECTORS, HOLDERS OR OWNERS OF 10 PERCENT OR MORE OF
VOTING STOCK, AND EMPLOYEES IN A MANAGERIAL OR EXECUTIVE CAPACITY.
A.

NAME

B.

4. WATER SOURCE ("X" one)

Public

TITLE

C. ADDRESS (No., Street, City and Zip Code

5. WASTE DISPOSAL ("X" one or both, as applicable)

Private

Sewer

Incinerator

6. PLANS FOR PROPOSED FACILITY (Make a drawing of floor plan or attach blueprints of your facility) SHOWING LO CATION FOR:
9 CFR 92.106
•

Bird Holding area(s)

• Clothes storage and change area(s)

• Necropsy room (showing entry and refrigeration)

• Equipment storage area(s)

• Feed storage area(s)

• Entries and exits

• Washing area(s) for equipment

• Office area(s)

• Shower area(s)

• Ventilation arrangements

ALL OTHER PROVISIONS MUST BE MET AS SPECIFIED IN THE REGULATIONS

CERTIFICATION
Application is hereby made for approval of a USDA Approved Quarantine Facility for bird importations. I certify that the information provided herein is
true and correct to the best of my knowledge and belief, and agree to comply with the applicable regulations in 9 CFR Part 92.
7. SIGNATURE OF IMPORTER

VS FORM 17-11
MAY 2003

8. PRINT NAME

PREVIOUS EDITIONS ARE OBSOLETE

9. DATE