VS 17-140 United States Origin Health Certificate

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 for these information are 0579-0020, 0101, and 0156. The time required to complete this information collection is estimated to average .75 to 1 hour 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 0579-0020, 0101 and 0156

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 requested is provided.

United States Department of Agriculture Animal and Plant Health Inspection Service Veterinary Services United States Origin Health Certificate (This document does not replace Certificate of Inspection of Export Animals, VS Form 17-27)

1. Consignor’s Name (last name, first name, middle initial, or business name)

2. Certificate Number

3. Page Number 1 OF

4. DATE ISSUED

5. U.S. PORT OF EMBARKATION (City and State)

6. STATE CODE

7. CONSIGNOR'S STREET ADDRESS (Mailing Address)

8. CONSIGNOR'S CITY (or Town)

12. CONSIGNOR'S STATE

13. STATE CODE

14. ZIP CODE

9. SEMEN ("X" if yes)

10. NO. DOSES OF SEMEN

11. TRANSPORTATION CLASS 1 - Rail 3 - Air 2 - Truck 4 - Ocean

16. CONSIGNEE'S NAME AND STREET ADDRESS (Mailing Address)

DESTINATION COUNTRY

ENTER CODE

15. SPECIES ("X" one - use VS Form 17-6 for Poultry) 01 BOVINE 02 PORCINE 03 OVINE 04 CAPRINE 05 EQUINE 08 OTHER WILDLIFE – MAMMAL

NEGATIVE TUBERCULIN READING 48 HRS 72 HRS

BRUCELLOSIS BLOOD SAMPLE COLLECTED

NEGATIVE RESULTS OF OTHER TESTS

09 OTHER (Specify)

CERTIFIED BRUCELLOSIS FREE AREA

DISEASE

DISEASE

DISEASE

If more lines are needed below - use VS Form 17-140A.

MODIFIED ACCREDITED AREA (TB)

DATE F

TYPE TEST

TYPE TEST

TYPE TEST

17. FARM ORIGIN Owner's name (Last name, two initials, or business name) Owner's street address Owner's city/town, State code (FIPS code on reverse) & zip code

18. INDIVIDUAL IDENTIFICATION (Instructions for columns A, B, C & D on reverse)

√ E

ID NO. OR DESCRIPTION A

AGE B

SEX C

BREED D

√ G

DATE H

VAC I

1/25 J

1/50 K

1/100 L

DATE M

DATE N

DATE O

VALID ONLY IF USDA VETERINARY SEAL APPEARS HERE

CERTIFICATION BY ISSUING VETERINARIAN This is to certify that the animals identified above were inspected by me on this date and found to be free from evidence of communicable diseases and insofar as can be determined exposure thereto; the premises of origin are not under Federal or State quarantine because of animal disease; the animals were all negative to the tests shown on the dates indicated. Arrangements have been made for the animals to be handled in a transporting vehicle that has been cleaned and disinfected since last used for livestock and for movement to the port of embarkation without exposure to other animals en route, except those meeting these health requirements. The shipment must be accompanied to the port of export with this certificate.

19. DATE ENDORSED

20. NAME OF ISSUING VETERINARIAN (Last name, first name, middle initial,- please print)

21. STATUS 2 Federal 1 State 3 Accredited

22. TOTAL NO. OF ANIMALS (Certified for export or donated semen) (Include numbers. From all attached VS Forms 17-140A)

24. NAME OF ENDORSING FEDERAL VET (Type, print, or stamp)

25. SIGNATURE OF ISSUING VETERINARIAN

23. Signature of Endorsing Federal Veterinarian

VS Form 17-140

SEP 2010