7011 Application for Registration

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 0579-0036. The time required to complete the 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				Every research facility, exhibitor, carrier, and intermediate handler not required to be licensed under Section 3 of the Animal Welfare Act, shall register with the USDA (7 U.S.C. 2136). This application provides information for such registration.		OMB Approved 0579-0036 Exp.xx/xxxx
U.S. DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE APPLICATION FOR REGISTRATION (type or print) new REGISTRATION			USDA USE ONLY
			Applicant should send completed form to this address
			Certificate no./customer no:		Renewal date
1. REGISTRANT (Name and permanent mailing address, including ZIP Code) County: Telephone:			2. LOCATION(s) OF BUSINESS, EXHIBITION SITE(s), OR RESEARCH FACILITIES (Use additional sheets if necessary)
3. previous USDA registration number (If any)			4. active usda certificate Number(s) in which you have an interest:
5. ARE YOU USING FEDERAL FUNDS TO CARRY OUT RESEARCH, TESTS, OR EXPERIMENTS? Yes No		6. Type of Registration: Class E - Exhibitor Class H - Intermediate Handler Class R - Research Facility Class T - Carrier
7. FEDERAL FUND TYPES: Award Contract Grant Loan		8. Type of organization: Individual Corporation Partnership Other (University, State, Municipality, LLC, Trust)
9. if individual identify each owner, if partnership identify each partner or officer, if corporation, identify principal officers for research facilities include the institutional officIAL (Use separate sheet if needed)
A. NAME	B. TITLE			C. ADDRESS (full address, including ZIP Code)

CERTIFICATION

I hereby register as a Research Facility, Exhibitor, Carrier, or Intermediate Handler under the Animal Welfare Act, 7 U.S.C. 2131 et seq. and I certify that the information provided herein is true and correct to the best of my knowledge. I hereby acknowledge receipt of and agree to comply with all the regulations and standards contained in 9 CFR, Subpart A, parts 1, 2 and 3. I certify that all listed persons are 18 years of age or older.

10. SIGNATURE

11. NAME AND TITLE (Type or Print)

12. Social Security Number or Employee Identification Number

13. DATE SIGNED

APHIS Form 7011 ACKNOWLEDGMENT OF RECEIPT OF REGULATIONS AND STANDARDS

APR 2009