Form VS 16-3 VS 16-3 Diagnostic Specimen Import Permit Application

Failure to supply all applicable information can delay the processing of this application.				Please type or print clearly.
No controlled material, organisms, or vectors may be imported or moved interstate unless the data requested on this form is furnished and certified (9 CFR Parts 94, 95, and 122).		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 numbers of this collection of information are 0579-0015, 0579-0094, 0579-0183, 0579-0213, 0579-0245, and 0579-301. The estimated time to complete this information collection is estimated to average .5 hours per response, including the time for reviewing existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.			OMB Approved 0579-0015, 0579-0094, 0579-0183, 0579-0213, 0579-0245, and 0579-0301
United States Department of Agriculture Animal and Plant Health Inspection Service Veterinary Services National Center for Import-Export, Products Program 4700 River Road, Unit 40 Riverdale, MD 20737-1231 Application for Permit to: Import or Transport controlled material or organisms or vectors			1. Mode of transportation (Please ”X”): AIR SEA LAND ANY
			2. United States Ports of Entry
3. Importer: (Name, organization, complete address, telephone and fax numbers or individual who will receive and be responsible for the imported material)			4. Shipper(s): (Name and Address of producer/shipper)
5. Describe the material to be imported (Provide the following information, as applicable: Animal species and tissue of origin of animal product, country of origin of the animal for which raw animal product was sourced, processing country, recombinant system and genetic inserts, antibody immunogenic, stabilizers, nutritive factors of animal origin in media.) (Complete VS FORM 16-7 for cell culture and their products.)
6. Quantity, frequency or importation, and expected completion date (Estimate)
7. Proposed use of material and derivatives (Also, for animal pathogens or vectors, describe facilities/biosafety procedures)
8. If for Use in Animals, Specify the Animal Species
9. Treatment of Material Prior to Importation into the United States (Processing/purification methods, including time at specific temperatures, pH, other treatments, disease safeguards, etc.)
10. Method of Final Disposition of Imported Material and Derivatives
I Certify as authorized by the company/institution that I represent, that this material will be used in accordance with all restrictions and precaution as may be specified in the permit.
11. signature of applicant			12. typed name and title
13. date	14. APHIS User Fee Credit Account No. or Method of user fee payment (for VISA or MasterCard include number and expiration date).

VS FORM 16-3

APR 2009