VS 4-39A Patron Listing Cooperating

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not 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 0579-0047. The time required to complete this information collection is estimated to average .025 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

OMB Approved 0579-0047

UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE VETERINARY SERVICES

PATRON LISTING COOPERATING

RESULTS CODE

STATE

1-Other 2-Negetaive

3-Not In 4-Suspicious

5-Dry 6-Missed

7-Sold Out

PLANT NAME

PLANT ADDRESS

COUNTY CODE

PLANT NUMBER

DATE OF LAST TEST

PATRON NUMBER

PATRON NAME

PATRON ADDRESS

RESULTS

COUNTY

DISTRICT/ TOWNSHIP

PRECINCT/SECTION

HERD NO.

VS 4-39A APR 2009