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

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 0579-0048. The time required to complete this information collection is estimated to average .5 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 0579-0048

This certificate is authorized by law (21 U.S.C. 112). While you are not required to respond, no health certificate can be validated unless the data required are provided.

UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE VETERINARY SERVICES CERTIFICATE FOR POULTRY OR HATCHING EGGS FOR EXPORT

1. DATE OF SHIPMENT

No. A

2. NAME AND ADDRESS OF EXPORTER (Include ZIP Code) FIPS STATE CODE (for USDA use only)

3. NAME AND ADDRESS OF IMPORTER FIPS COUNTRY CODE (for USDA use only)

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

5. VARIETY, STRAIN OR TRADE NAME

6. PRODUCT (X or check)

7. SEX (X or check)

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

9. NPIP APPROVAL NO.

Chicken Eggs

Turkey Eggs

Chicks

Poults

Other

Straight-run

Females

Males

Commercial Production Stock

Multiplier Breeding Stock

Primary Breeding Stock

10. NPIP CLASSIFICATION-U.S. (X or check)

Eggs-Type

Meat-Type

Other

Eggs-Type

Meat-Type

Other

Eggs-Type

Meat-Type

Other

Pullorum-Typhoid Clean`

M. Gallisepticum Clean

M. Meleagridis Clean

Sanitation Monitored

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, omithosis, 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 pat 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, omithosis 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)

USDA VETERINARY SEAL (if required)

14. TYPED NAME OF ISSUING VETERINARIAN

15. SIGNATURE OF ISSUING VETERINARIAN

16. STATUS 1. State 2. Federal 3. Accredited

17. DATE ISSUED

18. SIGNATURE OF ENDORSING FEDERAL VETERINARIAN (if required)

19. DATE ENDORSED

VS Form 17-6 MAY 2009