Vs 10-4a Continuation Sheet Specimen Submission

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.ccording to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid O M control
~
umber. The valid OM6 control numberrs for this information is 0570-0090 and 0579-0212. The time required to complete this information wllection is
stimated to average . 5 hours per response for 0579-0090 and ,333hours per response for 0579-0212. includingthe time to review instructions, search existing
ata resources, gathering and ma~ntainingthe data needed, and completing and reviewing the wllection of infomation.

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FORM APPROVED
OMB NUMBER
05794090 and 05784212
PAGE

U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
NATIONAL VETERINARY SERVICES LABORATORES
AMES. IOWA 50010

INSTRUCTIONS: Use this form only as a continuation of
information on VS FORM 10-4.

OF

CONTINUATION SHEET FOR SPECIMEN SUBMISSION
13. REFERRAL NUMBER

. NAME OF OWNEWBROKER (Lsst, First, MI)
STATE

:IN
I

1.

Sample ID

IDENTIFICATION

IDENTIFICATION
SEX

AGE

Anlmal IDIBreed

Sample ID

.

!

VS FORM 10-4A
(JUN 92)

Re~lacesAPHIS FORM 8004A (10190) whrch

IS

obsolele

AGE

Anlmal IDIBreed

-

SEX