Form VS 1-27 VS 1-27 Permit for Movement of Restricted Animals

PERMIT FOR MOVEMENT OF RESTRICTED ANIMALS
INSTRUCTIONS

• USE A SEPARATE FOR M f OR EACH SPECI ES
• PRESS HARD- YOU ARE MAKING 5 COPIES
• INSE RT COVER UNDER EACH SET TO USE AS WRITING REST

• CO MP LETE EACH APP LICABLE ITEM-OMISS IONS WILL YOlO THE PERMIT

IF SHIPMENT IS RESTRICTED FOR MORE THAN
•

m~E

DISEASE

LIST EACH DISEASE IN ITEM 8. AND RELATED DATA IN ITEMS 9,10, & 11.
CONSULT VS MEMO RANDUMS FOR THE APPROPRIATE DISEASE PROGRAM
INSTRUCTIONS.

DISTRIBUTION OF FORM:
•

PART 1·0RIGINAL·TO ACCOMPANY SHIPMENT

•

PART 2·MAIL TO DESTINATION OF SHIPMENT

-

G 75076

__
.. ENCLOSE A PREADORESSED ENVELOPE TO WHERE THIS COPY
SHOULD BE MAILED-AFTER ITEMS 26 TH RU 34 HAVE BEEN COM·
PLETED.

•

PART 3-TO STATE OF DESTINATION (VS OFFICE)

•

PART 4·10 STATE OF ORIGIN (VS OFFICE)

•

PART S.RETAIN BY ISSUING OFF ICI AL

G 75100

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U,5 , DfPAllTJol ENT Of AG RICULlURE
A" ' MAL AND PLANT HEALTH IN5PE cno .. 5ERVICE
VETERINARYSERVICES

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I No.

APPR OVED
Olllil "10 O ~1~ ·() O:' 1
~ OH M

, S TAff WHERE IS SUED

P E R M IT F OR M O VEMEN T O F R E STRICT ED ANI MA L S

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G 75077

USE A S EPAR ...t e f O RM FOR EACH SPEC IES

• NAJolE AND ADDRESS Of SHIPPE R O R CO NS' G!\lOR //"cl"dB Zip

6, MOVEJol EHT TO BE

C Od B}

.......... .. ........... ..... ...... ... ... .. .... .. .. ... .................... .... . .. .. ....
.. .... ..... .......... ........... ........ ... ... .... .. ... ... ..... ... .... ....... ... .. ....

o

INT ERSTAT E

D

IN T R AS TA TE

o

QUA RA NTINE o

S L A UG H T E R

1. MOVEJol E!\lT f OR

I , DISEASE

2, CONS IGNEE (DB.lmB I,,,.-, N8m B 8 ""

~/,,, ..,

No
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........ ... .... ..... ..... ..... .
...... .. .. ..... ... .. .. ... .... . ....... ... .... ... ... .. .... ..... .. ....... .. ... ..... .. ..

I I

9 , STATUS Of ANIMALS

mc/we Z'p C" del

No
EJqJO>.eK)

It,,,,,,

!lHEED

'0 ""W,, '" "';<;O"'''flI;''

ohy'tJlu

S EX

",nh

DiSE ASE
BRAND

tt,,, ' Uqun" ' " " n l§

20 TIME ISS UED

19 DATE IS SUED

OTHER ,DENTIFICATION
/Compl"'B fro .J

0'

S ia l"

.""

FocI""al

VOID AfTER
21 , DAlE

I r r.

TIlliE

WA R N ING TO O W NER, S H IP PE R A ND TR UCKE R· LIVES TOCK M US T B E DE LIVE RED T O CO NS IG NEE W ITHO UT D IVE RS IO N
F ",,,,,,,I
It, n lOVtl 110" .. " " " .. 1, " k"'1" ....IJ It .... " " , ,,, I,,. s l,, l,, "" "'1'1 III .... .. ,," Id" "'" ","h lh" 1" <1"" ~'''''s 0 1 "1l1,hw'UI" Foo.",,,
I o " IJ" ,sl.. ,Kl 1t'.. 1 u 'S .. ..." ,I""u tt
w,lt, tlK'SI." y Sia l" la ws al"j ' t."Yul" ' II' ''s y o...
of h..." slnc.k "ml , ",uIUy l have ,lIIa llg OO
l'It.il ulal " " 's I .. Iso u' MI",sl",Kl thill s uch a m"'''' s mus1
' " WIll " "a " ye lUI .. cupy 0 1 l h,s """"" 10 i1C(;[)ffi fli'0 Y II,,, lftl",~ l a l" s l" l'fII.m l /lttll 00 .....,,""' 00 wlllt nM~ a llu..." '1eS';" '1t'd /lo"""ls

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aa

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t:urnr>1Y

""",,1.1 "'0"'''''''''''

SIGNATURE Of OW!\lER OF S HIP PER

2• .

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I <.e11,l y II" .,
a ""' ... '~ , It>scnt -.t "" Ih' , 1"" " '" wa ll. , oc el.ttd
on lit.. d a l" 'nlhca,ud rn ,I",,, 2 9
16 PLACE ANIMALS RECEIVED

"

DATE AND TIlliE
S EALS BROKE

VS FO RM 1-27

(JU N 89 )

3 1. Al11HDRllE D SIGNATURE

nne

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'" .... crooe.....'" "" II, th e lequ " "m,m ls 0 1 Ihe S tate "od F ed" , ,,1 tOQula lion s

NO. ANIMALS RECEIVED

DATE CLEANED AND
DISINf ECTED II'

" 'u'l""",)'

o SH IP P~ A

owNrR

""rt s l"oyhl""",II' lo"''' IIl''lOd

U. DATE ANIMALS ARRIVED

2 S, DATE SIG NED

"

29 , DATE SLAUGHTERED.oUARANTINED

S IGNAlU RE Of INSP ECTO R

3. DATE SIG NED

PART 1 - ACCOM PANY SHIPMENT

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