Form VS 4-9 VS 4-9 Request for Reagents or Supplies

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-xxxx. The time required to complete this information collection is estimated to
average .25 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.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
NATIONAL VETERINARY SERVICES LABORATORIES
P.O. BOX 844, 1920 DAYTON AVENUE, AMES, IA 50010
PHONE: 515-337-7550 or 7725
FAX: 515-337-7402
EMAIL: [email protected]
1. SHIP TO: (Business Name and Name of Individual Contact )

REQUEST FOR REAGENTS OR SUPPLIES
2. NVSL
SUBMITTER ID

EMAIL ADDRESS

3. BILL TO

Check if same as Block 1 (SHIP TO)

EMAIL ADDRESS

PHONE NUMBER

FAX NUMBER

SHIPPING ADDRESS (Street, City, State, ZIP Code)

PHONE NUMBER

FAX NUMBER

BILLING ADDRESS

4. PAYMENT METHOD
USER FEE ACCOUNT NUMBER

CHECK/MONEY ORDER
(Enclosed, payable to USDA in U.S. dollars)

Number:
CREDIT
CARD
Exp Date:

5. REAGENTS AND SUPPLIES REQUESTED (See instructions. Please limit to 10 items per form))
REAGENT CODE
NUMBER

REAGENT OR ITEM NAME

6. PRINTED NAME AND SIGNATURE OF REQUESTOR AND DATE

7. PHONE NUMBER OF REQUESTOR (IF NOT
PROVIDED IN BLOCK 1 OR 3)

VS FORM 4-9 (JUL 2014)

OMB Approved
0579-xxxx
Exp.: XX/XXXX

8. DATE OF REQUEST

QTY

REMARKS

NVSL USE ONLY
ORDER NUMBER

VS FORM 4-9 INSTRUCTIONS

Complete the form according to the following instructions. Incomplete or incorrectly completed forms will delay
shipment and may result in errors. Please print legibly or type all information.
Orders are accepted via mail, fax, or email. Do not submit the same order via more than one method or it will be
duplicated.
1. The name of a contact person and a complete shipping address is required. Do not use P.O. Box numbers. A telephone
number is required. No orders will be shipped unless a telephone number is provided. Provide a FAX number and/or
email address, if available.

2. If you have previously ordered reagents or supplies from the NVSL, you will have been assigned a NVSL identification
number; this is the number to enter in block number 2. If you are a new customer, NVSL will assign an identification
number when the order form is received.
3. If the billing address is the same as the shipping address, check the box to indicate this. Otherwise, provide a complete
billing address, phone number, and the name of a contact person for billing.
4. Prepayment is required unless the requested items are to be billed to a user fee account number. If services are to be
billed to a user fee account, be sure to include the 11-digit account number in the applicable space provided. Prepayment
may be in the form of check, money order, or credit card. Make check or money order payable to "USDA" in U.S. dollars
and attach to the order form. If paying by credit card, include the account number and expiration date. See
http://www.aphis.usda.gov/animal_health/lab_info_services/payment.shtml or contact the NVSL for a list of currently
accepted credit cards.
5. A catalog of available reagents and supplies is posted at http://www.aphis.usda.gov/animal_health/lab_info_services/
reagents.shtml or may be requested from NVSL.
The Reagents and Supplies Requested section must include the reagent code number (obtained from the catalog),
reagent or item name, and the quantity requested. Additional comments may be recorded in the Remarks section.
6. The name of the person (print or type) authorizing the request and his/her signature must be included.
7. If the telephone number of the person authorizing the request is different from the telephone number of the contact
person, please complete this section.
8. Add the date of the request.
***If you are requesting a live pathogen, be sure to include a copy of your valid USDA veterinary permit with your order.***