7011 Application for Registration

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 0579-0036. The time required to complete the
information collection is estimated to average .25 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

Every research facility, exhibitor, carrier, and
intermediate handler not required to be licensed
under Section 3 of the Animal Welfare Act, shall
register with the USDA (7 U.S.C. 2136). This
application provides information for such
registration.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE

OMB Approved
0579-0036
Exp.: XX/XXXX

USDA USE ONLY

APPLICATION FOR REGISTRATION

Applicant should send completed form to this address:

(TYPE OR PRINT)

CERTIFICATE NO./CUSTOMER NO:

NEW REGISTRATION
1. REGISTRANT (Name and permanent mailing address, including ZIP Code):

COUNTY:

RENEWAL DATE

2. LOCATION(s) OF BUSINESS, EXHIBITION SITE(s), OR RESEARCH FACILITIES
(Use additional sheets, if necessary):

TELEPHONE:

3. PREVIOUS USDA REGISTRATION NUMBER (If any):

4. ACTIVE USDA CERTIFICATE NUMBER(S) IN WHICH YOU HAVE AN INTEREST:

5. ARE YOU USING FEDERAL FUNDS TO CARRY OUT
RESEARCH, TESTS, OR EXPERIMENTS?

Yes

6. TYPE OF REGISTRATION:

7. FEDERAL FUND TYPES:

Award

Class E - Exhibitor

Class H - Intermediate Handler

Class R - Research Facility

Class T - Carrier

No

Contract

8. TYPE OF ORGANIZATION:

Grant

Individual

Loan

Corporation

Partnership

Other (University, State, Municipality, LLC, Trust)
9. IF INDIVIDUAL, IDENTIFY EACH OWNER, IF PARTNERSHIP IDENTIFY EACH PARTNER OR OFFICER, IF CORPORATION, IDENTIFY PRINCIPAL OFFICERS FOR RESEARCH FACILITIES
INCLUDE THE INSTITUTIONAL OFFICIAL (Use separate sheet, if needed)
A.

NAME

B.

TITLE

C.

ADDRESS (full address, including ZIP Code)

CERTIFICATION
I hereby register as a Research Facility, Exhibitor, Carrier, or Intermediate Handler under the Animal Welfare Act, 7 U.S.C. 2131 et seq. and I certify that the information provided herein is true and correct
to the best of my knowledge. I hereby acknowledge receipt of and agree to comply with all the regulations and standards contained in 9 CFR, Subpart A, parts 1, 2 and 3. I certify that all listed persons
are 18 years of age or older.
10. SIGNATURE

11. NAME AND TITLE (Type or Print)

12. SOCIAL SECURITY NUMBER OR
EMPLOYEE IDENTIFICATION NUMBER

ACKNOWLEDGMENT OF RECEIPT OF REGULATIONS AND STANDARDS
APHIS FORM 7011
APR 2009

13. DATE SIGNED