VS 5-29 Cooperative State - Scrapie Control Program

Scrapie Flock Certification, Animal Identification, and Indemnification Procedures

VS 5-29 DEC 2011

Private Sector

OMB: 0579-0101

Document [pdf]
Download: pdf | pdf
$FFRUGLQJWRWKH3DSHUZRUN5HGXFWLRQ$FWRIDQDJHQF\PD\QRWFRQGXFWRUVSRQVRUDQGDSHUVRQLVQRWUHTXLUHGWRUHVSRQGWRDFROOHFWLRQRILQIRUPDWLRQXQOHVVLWGLVSOD\VDYDOLG20%FRQWUROQXPEHU
7KHYDOLG20%FRQWUROQXPEHUIRUWKLVLQIRUPDWLRQFROOHFWLRQLV7KHWLPHUHTXLUHGWRFRPSOHWHWKLVLQIRUPDWLRQFROOHFWLRQLVHVWLPDWHGWRDYHUDJHKRXUVSHUUHVSRQVHLQFOXGLQJWKHWLPHIRU
UHYLHZLQJLQVWUXFWLRQVVHDUFKLQJH[LVWLQJGDWDVRXUFHVJDWKHULQJDQGPDLQWDLQLQJWKHGDWDQHHGHGDQGFRPSOHWLQJDQGUHYLHZLQJWKHFROOHFWLRQRILQIRUPDWLRQ
OMB APPROVED 0579-0101
67$7(
ALL INCOMPLETE RECORDS WILL BE RETURNED FOR COMPLETION
EXP
DATE XX/XXXX


$

&223(5$7,9(67$7()('(5$/6&5$3,(&21752/352*5$0

5()(55$/12

6&5$3,(7(675(&25'
),567

&2817<2)2:1(5

)/2&.2:1(5
61$0(/$67

)/2&.,'

)/2&.2:1(5
6&203/(7($''5(66

&2817<2))/2&.

)/2&.2:1(5
67(/(3+21(180%(5

5($621)257(67



)/2&.5(
&(57,),
&$7,21



+,*+5,6.
75$&(72
)/2&.



2:1(5
6
5(48(67

5(7(67

,1)(&7('
256285&(
5666326

,03257('

9(7(5,1$5,$1
66,*1$785(

7(/(3+21(12

&2//(&7,21'$7(

*(127<3(/$%7851$5281'7,0(
'$<7851$5281'

)$;1225(0$,/$''5(66

$*5((0(1712

7(677<3(

&2'2121/<

)/2&.67$786

&2'21
&2'21

7+,5'(<(/,'(TE)

27+(5

6)&3

(;326('

,1)(&7('

121(

6285&(

,19(67

27+(5

2IILFLDO,'1XPEHUV

2WKHU,'1XPEHUV

127(6DPSOHQXPEHUVRQVSHFLPHQVPXVWEHWKHVDPHDVOLVWHGRQWKLVIRUP
'6(1DPH

&(57,),&$7,21)253$<0(17
2ZQHU
V
&RRSHUDWLYH
6WDWH)HGHUDO
([SHQVH
$JUHHPHQW
([SHQVH
,FHUWLI\
7KDWWKLVWHVWZDVPDGHE\PHRQWKHDQLPDOVLGHQWLILHGEHORZRQWKHGDWHVDV
HQWHUHGLQDSSURSULDWHVSDFHV
7KDWZKHQSD\PHQWLVFODLPHGDWSURJUDPH[SHQVHLQDFFRUGDQFHZLWK
DJUHHPHQWQXPEHUEHORZQRSD\PHQWKDVEHHQRUZLOOEHUHFHLYHGIURPDQ\
RWKHUVRXUFH

0,;('

&2'2121/<

6SHFLPHQ

727$/2)
6$03/(6

9(7(5,1$5,$1
6$''5(66

27+(5

0,66,1* 
(;326('
(:(0(


12

3(5621,'9(7(5,1$5,$161*'

9(7(5,1$5,$1
61$0(Please print)

*2$7

'$<7851$5281'

27+(5

<(6

.,1'2))/2&.

6+((3

35(9,2867(67'$7(

)$5012

122)$1,0$/6,1)/2&.


,1)(&7('
256285&(
1275666



6(&

&203/(7()/2&.7(672)$//(/,*,%/($1,0$/6



6859(,//$1&(

0,

'HVLJQDWLRQ
SRVVXV
H[SPHQD

$JH

%UHHG
6H[
UG(\HOLG,QIR
PIFP LIXQNQ
IDFH
/

5

6HHQ
8QVHHQ

/

5

6HHQ
8QVHHQ

/

5

6HHQ
8QVHHQ

/

5

6HHQ
8QVHHQ

/

5

6HHQ
8QVHHQ

/

5

6HHQ
8QVHHQ

/

5

6HHQ
8QVHHQ

/

5

6HHQ
8QVHHQ

&LUFOHLIWKHUGH\HOLGWLVVXHFDPHIURPWKH/HIWRU5LJKWH\H
&LUFOHLIWKHO\PSKRLGWLVVXHZDV6HHQRU8QVHHQ
5HPDUNV

$GGUHVV

3KRQH1XPEHU

'$7(

2:1(5
66,*1$785(

)D[1XPEHU
(0DLO

96)250
'(&

,KHUHE\DFNQRZOHGJHUHFHLYLQJDFRS\RIWKLVUHFRUGZKLFK,KDYHH[DPLQHGDQGILQGFRUUHFW


File Typeapplication/pdf
File TitleInForms - vs5-29.wpf
AuthorKHBROWN
File Modified2011-12-13
File Created2007-11-19

© 2024 OMB.report | Privacy Policy