Form VS 17-6 VS 17-6 CERTIFICATE FOR POULTRY OR HATCHING EGGS FOR EXPORT

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 0579-0048. The time required to complete this information collection is estimated to average .5 hours per response, including the time
for reviewing instructions, searching data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

FORM APPROVED
OMB NO. 0579- 0048

This certificate is authorized by law (21 USC 112). While you are not required to respond, no health certificate can be validated unless the data required are provided.
1. DATE OF SHIPMENT

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

No. A

CERTIFICATE FOR POULTRY OR HATCHING EGGS FOR EXPORT
2. NAME & ADDRESS OF IMPORTER

2. NAME & ADDRESS OF EXPORTER (Include Zip Code)

FIPS STATE CODE (for USDA use only)

NO.

Sanitation
Monitored

10. NPIP CLASSIFICATION - U.S.
(X or check)
M.
Gallisepticum
Clean
M.
Meleagridis
Clean

Other

Eggs-Type

Primary
Breeding
Stock
Meat-Type

Other

Other

Eggs-Type

Meat-Type

Meat-Type

Multiplier
Breeding
Stock

Commercial
Production
Stock
Males

9. NPIP APPROVAL

8. TYPE (Intended use)
(X or check)

Eggs-Type

Females

Poults

Other

Chicks

5. VARIETY, STRAIN
OR TRADE NAME

Turkey Eggs

Chicken Eggs

4. QUANTITY/UNIT
(Eggs-Dozen)
(Poultry-Number)

Straight-run

7. SEX
(X or check)

6. PRODUCT
(X or check)

Pullorum Typhoid Clean

FIPS STATE CODE (for USDA use only)

OTHER
(Specify)

11. TOTAL NO. OF UNITS CERTIFIED FOR EXPORT

12. CHECK APPROPRIATE CERTIFICATION BELOW (A OR B)
A.

Certificate for Hatching Eggs and Newly Hatched Poultry, which have not been fed or watered. This is to certify that: (1) the flock or flocks and the hatchery or
hatcheries from which the above-described hatching eggs or newly hatched poultry originated were inspected by me or another accredited veterinarian within 30
days prior to shipment of above hatching eggs or setting of eggs for above shipment of day old chicks and found free from evidence of communicable diseases
and insofar as can be determined have not been exposed to Newcastle disease, fowl plague, fowl typhoid, ornithosis, and pullorum disease; (2) during the usual
routine inspection of the flock or flocks there was no visible evidence of communicable diseases observed on the inspection dates listed in item 13 below; (3)
the National Poultry Improvement Plan classification is as indicated in item 9 above; and (4) the prospective exporter has been advised that the hatching eggs
must be clean and that the shipment must be made in new, clean containers.

B.

Certificate for Poultry other than Newly Hatched Poultry Specified in Certificate A. This is to certify that: (1) on this date all poultry shown in item 5 above,
including all other poultry maintained in the flock, were inspected by me on the premises of origin within the past 30 days and found free from evidence of
infectious and contagious diseases and insofar as can be determined have not been exposed to Newcastle disease, fowl plague, fowl typhoid ornithosis, and
pullorum disease; and (2) the prospective exporter has been advised that shipment must be made in new containers or clean containers which have been
properly cleaned and disinfected.

13. REMARKS OR ADDITIONAL INFORMATION (If needed)

14. TYPED NAME OF ISSUING VETERINARIAN

15. SIGNATURE OF ISSUING VETERINARIAN

16. STATUS
1. State

2. Federal

3. Accredited

18. SIGNATURE OF ENDORSING FEDERAL VETERINARIAN (If required)
USDA VETERINARY SEAL (If required)
VS FORM 17-6 (SEPT 95)

17. DATE ISSUED
Mo
Da

Yr

19. DATE ENDORSED
Mo
Yr
Da