VS 16-3 Application for Permit to: Imprt or Transport Controlled

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 OMB control number for this information collection is 0579-0367. The time required to complete this information collection is estimated to average .5 minutes 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 0579-0367
UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE VETERINARY SERVICES REPORT OF ENTRY, SHIPMENT OF RESTRICTED IMPORTED ANIMAL PRODUCTS AND ANIMAL BY-PRODUCTS, AND OTHER MATERIAL							1. CASE NO.
							2. PORT OF ENTRY
A. REPORT OF ENTRY AND FORWARDING OF SHIPMENT FROM FIRST PORT OF ARRIVAL
3. NAME AND ADDRESS OF IMPORTER OR SHIPPER (Include ZIP Code)				4. COUNTRY OF ORIGIN					5. CUSTOMS ENTRY NO.
				6. PRODUCT OR MATERIAL					7. DATE OF ARRIVAL
	8. VETERINARIAN IN CHARGE IN STATE WHERE APPROVED ESTABLISHMENT IS LOCATED (Include ZIP Code)						9. NAME OF VESSEL
							10. NAME OF CARRIER (Include R.R. Car No. or Truck License No.)
							11. SEAL NOS. OR QUARANTINE TAPE
12. TOTAL QUANTITY RECEIVED AT PORT OF ARRIVAL (Lbs. only)					13. NO. UNITS RECEIVED AT PORT OF ARRIVAL (Specify Carton, Boxes, Bundles, etc.,)
14. NAME AND ADDRESS OF APPROVED ESTABLISHMENT (Include ZIP Code and phone no.)							FROM PORT OF ENTRY TO APPROVED ESTABLISHMENT
							15. NO. LBS.		16. NO. UNITS
17. REMARKS
18. PRINTED NAME AND SIGNATURE OF INSPECTOR						19. PPQ STATION				20. DATE
B. REPORT OF RECEIPT AND TREATMENT BY ESTABLISHMENT (To be completed by Approved Establishment)
21. DATE RECIEVED		22. NAME OF APPROVED ESTABLISHMENT						23. WAS SHIPMENT INTACT Yes No (If “No” explain in item 30)
24. DATE TREATMENT COMPLETED		25. WERE R.R. CARS, TRUCKS, ETC. CLEANED AND DISINFECTED? Yes No						26. DISINFECTANT USED
27. METHOD OF TREATMENT								28. DISPOSITION OF REFUSE
29. REMARKS
30. PRINTED NAME OF APPROVED ESTABLISHMENT OWNER			31. SIGNATURE OF APPROVED ESTABLISHMENT OWNER							32. DATE

VS FORM 16-78

APR 2009

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 OMB control number for this information collection is 0579-XXXX. The time required to complete this information collection is estimated to average .5 minutes 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-XXXX
UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE VETERINARY SERVICES REPORT OF ENTRY, SHIPMENT OF RESTRICTED IMPORTED ANIMAL PRODUCTS AND ANIMAL BY-PRODUCTS, AND OTHER MATERIAL					1. CASE NO.
					2. PORT OF ENTRY
A. REPORT OF ENTRY AND FORWARDING OF SHIPMENT FROM FIRST PORT OF ARRIVAL
3. NAME AND ADDRESS OF IMPORTER OR SHIPPER (Include ZIP Code)		4. COUNTRY OF ORIGIN				5. CUSTOMS ENTRY NO.
		6. PRODUCT OR MATERIAL				7. DATE OF ARRIVAL
	8. VETERINARIAN IN CHARGE IN STATE WHERE APPROVED ESTABLISHMENT IS LOCATED (Include ZIP Code)				9. NAME OF VESSEL
					10. NAME OF CARRIER (Include R.R. Car No. or Truck License No.)
					11. SEAL NOS. OR QUARANTINE TAPE
12. TOTAL QUANTITY RECEIVED AT PORT OF ARRIVAL (Lbs. only)			13. NO. UNITS RECEIVED AT PORT OF ARRIVAL (Specify Carton, Boxes, Bundles, etc.,)
14. NAME AND ADDRESS OF APPROVED ESTABLISHMENT (Include ZIP Code and phone no.)					FROM PORT OF ENTRY TO APPROVED ESTABLISHMENT
					15. NO. LBS.	16. NO. UNITS
17. REMARKS
18. PRINTED NAME AND SIGNATURE OF INSPECTOR				19. PPQ STATION			20. DATE

__________________________________________________________________________________________________________________________________________

VS FORM 16-78

APR 2009

COPY DESIGNATIONS

BOTTOM RIGHT CORNER- RED INK

PART 1 – ORIGINAL

PART 2 – SHIPPING COPY (To accompany shipment)

PART 3 – VETERIANARIAN IN CHARGE

PART 4 – INSPECTOR’S FILE COPY (Where prepared)

******NOTE FOR PRINTING

PARTS 1 AND 2 – FULL SHEET TO NO. 32

PARTS 3 AND 4 – STOPS AT NO. 20

CARBON TO STOP AT THE BOTTOM LINE OF NOS. 18, 19, AND 20.

GLUED ACROSS TOP WITH PERFORATED STUB

** SEE SPEC SHEET FOR MORE INFOR**