VS 11-1A Application for Enrollment in the Federal Chronic Wastin

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.							OMB Approved 0579-0237 Exp. Date: XX/XXXX
United States Department of Agriculture Animal and Plant Health Inspection Service Veterinary Services			Application for Enrollment in the Federal Chronic Wasting Disease Voluntary Herd Certification Program for Farmed and Captive Cervids Continuation Sheet
Owner Information
1. Owner’s Name:
2. Mailing Address:
3. City:	4. County:				5. State:	6. ZIP Code:
7. Business Phone Number:		8. Cell Phone Number:		9. Business Fax Number:
10. Email Address:
11. Owner’s Name:
12. Mailing Address:
13. City:	14. County:				15. State:	16. ZIP Code:
17. Business Phone Number:		18. Cell Phone Number:		19. Business Fax Number:
20. Email Address:
21. Owner’s Name:
22. Mailing Address:
23. City:	24. County:				25. State:	26. ZIP Code:
27. Business Phone Number:		28. Cell Phone Number:		29. Business Fax Number:
30. Email Address:
Facility Information
31. Facility Name:
32. * Premises Identification Number (PIN):
33. Address:
34. City:	35. County:				36. State:	37. ZIP Code:
38. Business Phone Number:		39. Cell Phone Number:		40. Business Fax Number:
41. Business Email Address:
42. Facility Name:
43. * Premises Identification Number (PIN):
44. Address:
45. City:	46. County:				47. State:	48. ZIP Code:
49. Business Phone Number:		50. Cell Phone Number:		51. Business Fax Number:
52. Business Email Address:
53. Facility Name:
54. * Premises Identification Number (PIN):
55. Address:
56. City:	57. County:				58. State:	59. ZIP Code:
60. Business Phone Number:		61. Cell Phone Number:		62. Business Fax Number:
63. Business Email Address:

VS Form 11-1 A

AUG 2011