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 0579-0237. The time required to complete this
information collection is estimated to average 20 hours per
response, including the time for reviewing instructions, searching
existing data sources, gathering and maintain the data needed, and
completing and reviewing the collection of information.
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OMB
Approved
0579-0237
Exp.
Date:
XX/XXXX
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United
States Department of Agriculture
Animal
and Plant Health Inspection Service
Veterinary
Services
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Application
for Enrollment in the Federal Chronic Wasting Disease Voluntary
Herd Certification Program for Farmed and Captive Cervids
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A.
Owner Information
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1.
Owner’s Name:
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2.
Mailing Address:
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3.
City:
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4.
County:
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5.
State:
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6.
ZIP Code:
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7.
Business Phone Number:
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8.
Cell Phone Number:
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9.
Business Fax Number:
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10.
Email Address:
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B.
Facility Information
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11.
Facility Name:
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12.
* Premises Identification Number (PIN):
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13.
Address:
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14.
City:
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15.
County:
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16.
State:
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17.
ZIP Code:
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18.
Business Phone Number:
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19.
Cell Phone Number:
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20.
Business Fax Number:
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21.
Business Email Address:
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Mailing
address, if different from above:
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22.
Street or P. O. Box:
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23.
City:
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24.
County:
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25.
State:
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26.
ZIP Code:
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27.
County:
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28.
Manager’s Name (if
applicable):
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29.
Manager’s Cell Phone Number:
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C.
Breed
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30.
Number of Elk:
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31.
Number of Red Deer:
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32.
Number of Moose:
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33.
Number of White-Tailed Deer:
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34.
Number of Mule Deer:
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35.
Number of Black-Tailed Deer:
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36.
Number of Other Species (list
all types):
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I
have received a copy of the National Chronic
Wasting Disease Voluntary Herd Certification Program in farmed and
captive cervids and wish to participate in the program as
described therein.
I
understand that it is my responsibility to meet the requirements
of the program and all other applicable State and/or Federal laws
that pertain to my facility.
I
also understand that my herd enrollment may be suspended
or cancelled for
non-compliance or failure to document compliance with the program
requirements. This may also affect my herd’s certification
status level.
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37.
Signature of Owner or Authorized Agent:
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38.
Date:
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39.
Signature of Authorized APHIS Representative:
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40.
Date:
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Your
herd “Enrollment Date” for participation in the Herd
Certification Program will be determined by APHIS upon receipt of
this signed Application for Enrollment in the National Chronic
Wasting Disease Voluntary Herd Certification Program for Farmed
and Captive Cervids (VS Form 11-1), the completed initial whole
herd inventory, and documentation showing that all animals in the
herd, 12 months of age and older, were inspected and inventoried
within the previous 12 months.
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*
A unique number assigned by a State or Federal animal health
authority to a premises that is, in the judgment of the State or
Federal animal health authority, a geographically distinct
location from other livestock production units.
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For
further assistance, contact your State Area APHIS office.
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Mail
all documents to your State Area APHIS office.
For
animal co-owners or herds that are distributed between multiple
facilities, please complete a VS Form 11-1A.
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