Form APHIS-192 Application for Credit Account

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 0579-0055. The time required to complete this information collection is estimated to average .25 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 0579-0055 EXP XX/XXXX
APPLICATION FOR CREDIT ACCOUNT						USDA - APHIS
1. ACCOUNT TYPE (check applicable block(s)) Veterinary Services User Fee Plant Protection and Quarantine Reimbursable Overtime Other Services (Specify): ______________________________
2. APPLICANT NAME AND TITLE		3. FIRM NAME		4. DATE BUSINESS STARTED
5. BILLING ADDRESS			6. PHYSICAL LOCATION ADDRESS
7. TELEPHONE NUMBER ( ) ________________________________________________			8. FAX NUMBER ( ) ________________________________________________
9. ACCOUNT CONTACT NAME(S)
10. LIST FULL NAME,TITLE, HOME ADDRESS, AND TELEPHONE NUMBER FOR EACH PRINCIPAL OFFICER AND/OR OWNER
11. LIST OTHER TRADE NAMES, SUBSIDIARIES, BRANCHES, DIVISIONS, PARENTS, ETC.
12. ORGANIZATION TYPE Individual Partnership Corporation College or University State Gov't Federal Gov't Agency Other Services (Specify): ______________
13. NUMBER OF EMPLOYEES	14. DO YOU OWN YES OR RENT YOUR BUILDING YES IF RENTING, FROM WHOM: Name: _______________________________________ Telephone Number ( ) ___________________________
15. IRS TAX IDENTIFICATION NO. OR APPLICANT'S SOCIAL SECURITY NO. (If either is not provided, credit will not be issued) TAX IDENTIFICATION NUMBER: _________________________________________ SOCIAL SECURITY NUMBER: _______________________________________
16. FORMER BUSINESS LOCATION(S) FOR THE PAST SEVEN YEARS
PRIVACY ACT STATEMENT
Section 552 of Title 5 to the U.S. Code authorizes collection of this information. The primary use of this information is to gather data that will be used to establish a credit account for the purchase of goods and services from the Animal and Plant Health Inspection Service. User fees are authorized by Section 2509 (c) (1) of the Food, Agriculture, Conservation and Trade Act of 1990, amended by the Omnibus Budget Reconciliation Act of 1990, referred to as the 1990 Farm Bill, (21 U.S.C. 136 and 136a and 21 U.S.C. 135). Information collected will be used by Federal employees who have a need for the information in the performance of their official duties. Additional disclosures of this information may be made to Federal, State, local, or foreign agencies in relation to investigations of civil, criminal, or regulatory investigations or prosecutions, to the court of competent jurisdiction, to the United States Department of Agriculture's office of Inspector General's Office in connection with user fees reviews, and to consumer reporting agencies in accordance with Section 3711 (f) of Title 31. Your social security account number is solicited under the authority of the Internal Revenue Code (26 U.S.C. 6011 (b) and 6109) and Executive Order 9397, November 22, 1943, for use as a taxpayer and/or employee identification number. Disclosure of your social security number and other requested information is voluntary; however, failure to provide the information may result in disapproval of your request for credit.

APHIS FORM 192 Previous editions are obsolete

NOV 2010

APPLICATION FOR CREDIT ACCOUNT (Continued)
17. CURRENT BANK FOR YOUR CHECKING ACCOUNT NAME: ADDRESS: TELEPHONE NUMBER: ( ) FAX NUMBER: ( ) HOW LONG WITH CURRENT BANK ___________________________________			17. CURRENT BANK FOR YOUR SAVING ACCOUNT NAME: ADDRESS: TELEPHONE NUMBER: ( ) FAX NUMBER: ( ) HOW LONG WITH CURRENT BANK ___________________________________
19. - 22. LIST THREE BUSINESS/PROFESSIONAL CREDIT REFERENCES
NAME: ADDRESS: TELEPHONE NUMBER: ( ) FAX NUMBER: ( )	NAME: ADDRESS: TELEPHONE NUMBER: ( ) FAX NUMBER: ( )			NAME: ADDRESS: TELEPHONE NUMBER: ( ) FAX NUMBER: ( )
23. APHIS LOCATIONS TO BE NOTIFIED OF THE ACCOUNT NUMBER
AGREEMENTS
This information contained in this application is for the purpose of obtaining credit and is warranted to be true. I/We hereby authorize the agency to whom this application is made to investigate the information given herein pertaining to my/our credit and financial responsibilities. It is hereby agreed that the USDA, APHIS, will be reimbursed by the applicant upon completion of services. Payment will be made at the rate(s) established for services in accordance with 7 CFR Part 354 and 9 CFR Parts 97 and 130. If your company has more than one account, and any one account becomes past due, the entire company will be placed in a cash on delivery (COD) basis requiring payment at the time of service. Incomplete applications may delay establishing an account. Applicant's signature attests understanding, financial responsibility, authority, ability and willingness to pay all debts, interest, penalties, and administrative costs.
24. AUTHORIZED SIGNATURE(S) (Seal(s))		25. SIGNATURE NAME AND TITLE (Type or Print)			26. DATE
27. REMARKS
FOR OFFICIAL USE ONLY
ACCOUNT NUMBER(S) ASSIGNED		APPROVING ANALYST			DATE
AFTER COMPLETING THE FORM, SEND DIRECTLY TO: USDA, APHIS, FMD, ART OR FAX TO: (612) 370-2293 100 North Sixth Street, Suite 510C Minneapolis, MN 55403 FOR CUSTOMER SERVICE INQUIRIES, PLEASE CALL (877) 777-2128

APHIS FORM 192 (REVERSE)