7011a Application For Registration, Registration Update

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.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE

Every research facility, 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.

OMB Approved
0579-0036
Exp.: XX/XXXX

USDA USE ONLY
Applicant will send completed form to this address:

APPLICATION FOR
REGISTRATION
(TYPE OR PRINT)

CERTIFICATE NUMBER/CUSTOMER NUMBER

RENEWAL DATE

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

2. ALL BUSINESS NAMES AND SITE LOCATION(S).
Use additional sheets, if necessary

COUNTY:

TELEPHONE NUMBER:

3. PREVIOUS USDA REGISTRATION NUMBER (If any):

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

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

6. TYPE OF REGISTRATION:

Class H – Intermediate Handler
Yes

Class T – Carrier

No
Class R - Research Facility

7. TYPE OF ORGANIZATION:

Individual

Corporation

Other ___________________________________

Partnership

8. IF INDIVIDUAL, IDENTIFY EACH OWNER; IF PARTNERSHIP, IDENTIFY EACH
PARTNER OR OFFICER; IF CORPORATION, IDENTIFY PRINCIPAL OFFICERS
FOR RESEARCH FACILITIES INCLUDING THE INSTITUTIONAL OFFICIAL (Use
separate sheet, if needed)
A.
NAME
B.
TITLE

9. LIST THE TYPE OF ANIMAL(S) USED IN YOUR BUSINESS.

RODENTS

DOGS

NONHUMAN
PRIMATES

CATS

MARINE MAMMALS

WILD/EXOTIC
HOOFSTOCK

GUINEA PIGS

FARM ANIMALS

BEARS

HAMSTERS

WILD/EXOTIC
CANINES

RABBITS

WILD/EXOTIC
FELINES

(Do not include lab rats or
mice)

WILD/EXOTIC
MAMMALS
(Not listed elsewhere)

OTHER

CERTIFICATION
I hereby register as a Research Facility, 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)

ACKNOWLEDGMENT OF RECEIPT OF REGULATIONS AND STANDARDS
APHIS FORM 7011A
MAR 2013

12. DATE SIGNED