Form VS 17-140 VS 17-140 United States Origin Health Certificate

The certificate is authorized by law 21 U.SC 112). While you are not required to respond, no health certificate can be validated unless the data requested is provided.
U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

FORM APPROVED - OMB NO. 0579-0020

1. CONSIGNOR'S NAME (Last name, first name, middle initial or business name)

2. CERTIFICATE NO

UNITED STATES ORIGIN HEALTH CERTIFICATE

1

(This document does not replace Certificate of Inspection of Export Animals, VS Form 17-27)
4. DATE ISSUED

6. STATE CODE 7. CONSIGNOR'S STREET ADDRESS (Mailing Address)

5. U.S. PORT OF EMBARKATION (City and State)

10. NO. DOSES OF SEMEN

11. TRANSPORTATION CLASS
1 - Rail
3 - Air
2 - Truck

OF

8. CONSIGNOR'S CITY (or Town)

12. CONSIGNOR'S STATE
9. SEMEN ("X" if yes)

3. PAGE NO.

13. STATE CODE

16. CONSIGNEES NAME AND STREET ADDRESS (Mailing Address)

DESTINATION COUNTRY

14. ZIP CODE

ENTER CODE

4 - Ocean

15. SPECIES ("X" one - use VS Form 17-6 for Poultry)
01 BOVINE

02 PORCINE
05 EQUINE

03 OVINE

NEGATIVE TUBERCULIN
READING

04 CAPRINE

BRUCELLOSIS BLOOD SAMPLE
COLLECTED

08 OTHER WILDLIFE - MAMMAL
48 HRS.

09 OTHER (Specify)

If more lines are needed below - use VS Form 17-140A.
17. FARM ORIGIN
Owner's name (Last name, two initials, or business name)
Owner's street address
Owner's city/town, state code (FIPS code on reverse) & zip code

VALID ONLY IF USDA VETERINARY SEAL
APPEARS HERE

NEGATIVE RESULTS OF OTHER TESTS

72 HRS.
CERTIFIED BRUCELLOSIS
FREE AREA

MODIFIED ACCREDITED AREA (TB)

DISEASE

DISEASE

DISEASE

TYPE TEST

TYPE TEST

TYPE TEST

18. INDIVIDUAL IDENTIFICATION
(Instructions for columns A, B, C & D on reverse)
ID NO. OR DESCRIPTION
A

AGE
B

SEX
C

BREED
D

E

DATE
F

G

DATE
H

VAC
I

1/25
J

1/50
K

1/100
L

DATE
N

DATE
O

CERTIFICATION BY ISSUING VETERINARIAN
This is to certify that the animals identified above were inspected by me on this date and found to be free from evidence of communicable diseases and insofar as can be
determined exposure thereto; the premises of origin are not under Federal or State quarantine because of animal disease; the animals were all negative to the tests shown
on the dates indicated. Arrangements have been made for the animals to be handled in a transporting vehicle that has been cleaned and disinfected since last used for
livestock and for movement to the port of embarkation without exposure to other animals en route, except those meeting these health requirements. The shipment must be
accompanied to the port of export with this certificate.
19. DATE ENDORSED

20. NAME OF ISSUING VETERINARIAN (Last name, first name, middle initial,please print)

21. STATUS
1 State

24. NAME OF ENDORSING FEDERAL VET (Type, print, or stamp)
23. Signature of endorsing federal veterinarian

VS FORM 17-140 (MAR 98)

DATE
M

Previous edition may be used.

25. SIGNATURE OF ISSUING VETERINARIAN

2 Federal
3 Accredited

22. TOTAL NO. OF ANIMALS
(Certified for export or donated
semen) (Include nos. from all
attached VS Forms 17-140A)

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