VS 17-140A United States Origin Health Certificate - Continuation S

U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
CONTINUATION SHEET FOR

UNITED STATES ORIGIN HEALTH CERTIFICATE

OMB STATEMENT:
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 of this information collection is 0579-0020. The time required to complete this information
collection is estimated to average .50 hours 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.

NOTE: PART 2 VS RIVERDALE, MARYLAND - HAS A SEPARATE PAGE

READ INSTRUCTIONS FROM VS FORM 17-140

This certificate is authorized by law (21 USC 112), while you are not required to respond, no health certificate can be validated unless the data requested is provided. See reverse side for additional information. Form Approved OMB No. 0579-0020

U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

1. FIRST CONSIGNOR'S NAME (last name, first name, middle initial or business name)

2. CERTIFICATE NO.
FROM VS FORM 17-140

3. PAGE NO.

16. CONSIGNEE'S NAME

CONTINUATION SHEET FOR
BRUCELLOSIS BLOOD
SAMPLE COLLECTED

NEGATIVE TUBERCULIN
READING

UNITED STATES ORIGIN HEALTH CERTIFICATE

VS FORM 17-140a
(APR 2003)

Previous edition may be used.

72 HRS.

ID NO. OR
DESCRIPTION
A

AGE
B

SEX
C

BREED
D

DATE

U
E

Part 1 - ACCOMPANY
SHIPMENT

F

²

MODIFIED ACCREDITED AREA (TB)
18. INDIVIDUAL IDENTIFICATION

²

17. FARM ORIGIN
Owner's name (Last name, two initials, & business name)
Owner's street address
Owner's city/town, state code & zip code

48 HRS.

NEGATIVE RESULTS OF OTHER TESTS

CERTIFIED BRUCELLOSIS
FREE AREA

DISEASE

DISEASE

DISEASE

TYPE TEST

TYPE TEST

TYPE TEST

DATE
O

U

DATE

VAC

1/25

1/50

1/100

DATE

DATE

G

H

I

J

K

L

M

N

Part 2 - VS RIVERDALE,
MD (on seperate page)

Part 3 - PORT
VETERINARIAN

Part 4 -FIELD STATION

Part 5 - ISSUING
VETERINARIAN

READ INSTRUCTIONS FROM VS FORM 17-140

This certificate is authorized by law (21 USC 112), while you are not required to respond, no health certificate can be validated unless the data requested is provided. See reverse side for additional information. Form Approved OMB No. 0579-0020

U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

1. FIRST CONSIGNOR'S NAME (last name, first name, middle initial or business name)

2. CERTIFICATE NO.
FROM VS FORM 17-140

3. PAGE NO.

16. CONSIGNEE'S NAME

CONTINUATION SHEET FOR
NEGATIVE TUBERCULIN
READING

UNITED STATES ORIGIN HEALTH CERTIFICATE

48 HRS.

VS FORM 17-140a
(APR 2003)

Previous edition may be used.

ID NO. OR
DESCRIPTION
A

AGE
B

SEX
C

BREED
D

DATE

U
E

F

²

MODIFIED ACCREDITED AREA (TB)
18. INDIVIDUAL IDENTIFICATION

NEGATIVE RESULTS OF OTHER TESTS

72 HRS.

²

17. FARM ORIGIN
Owner's name (Last name, two initials, & business name)
Owner's street address
Owner's city/town, state code & zip code

BRUCELLOSIS BLOOD
SAMPLE COLLECTED

CERTIFIED BRUCELLOSIS
FREE AREA

DISEASE

DISEASE

DISEASE

TYPE TEST

TYPE TEST

TYPE TEST

DATE
O

U

DATE

VAC

1/25

1/50

1/100

DATE

DATE

G

H

I

J

K

L

M

N

PART 2 - VS RIVERDALE,MARYLAND