Application for Permit to Import or Transfer Live Bats

U. S. DEPARTMENT OF
HEALTH & HUMAN SERVICES
Public Health Service

APPLICATION FOR PERMIT TO IMPORT OR
TRANSFER LIVE BATS

FORM APPROVED
OMB NO. 0920-0199
EXP DATE 01/31/2017

Guidance for completing this form is available at http://www.cdc.gov/od/eaipp/importApplication/. This form may
be submitted by mail, fax, or email attachment to the Centers for Disease Control and Prevention, Import Permit
Program. Mailing Address: 1600 Clifton Road NE, Mailstop A-46, Atlanta, GA 30333. Fax: 404-471-8333.
E-mail: [email protected]. Telephone: 404-718-2077.
Please submit completed form only once by either email, fax, or mail
1. Permittee’s Last Name

SECTION A – PERSON REQUESTING PERMIT IN U.S.A.
2. Permittee’s First Name
3. MI
4. Permittee’s Organization

5. Address (NOT a post office box)

6. City

7. State

9. Permittee’s Telephone Number

10. Permittee’s FAX Number

11. Permittee’s E-mail

12. Secondary Contact’s Name

13. Secondary Contact’s Telephone

14. Secondary Contact’s E-mail

1. Last name of Sender

2. First

SECTION B – SOURCE OF BATS
3. MI
4. Organization

5. Address (NOT a post office box)

6.City

10. Telephone

8. Zip Code

7.State/Prov

11. FAX

8. Postal Code

9. Country

12. E-mail

SECTION C – DESCRIPTION OF BATS

Indicate Species of Bats and Total Number to be Imported (  Additional sheets attached):
1. Genus/Species of Bat

2. Common Name of Bat Species

3. Family

4. Total Number of Bats

5.  Wild-caught (indicate where bats were obtained, e.g., name of cave, game reserve, town, or province:_____________________
________________________________________________________________________________________________________)
 Captive bred
6. Proposed use of bats:  Education  Exhibition  Scientific  Other (Describe:__________________________________)
Note: If use is “scientific research,” attach research proposal and IACUC documentation
7. Describe how bats will be used (  Additional sheets attached):

8. Estimated completion date of work:
10. Intended final disposition:

 Euthanasia

9. Will animals be captive bred?
 Transfer

 Institutional use in perpetuity

 Yes

 No

APPLICATION FOR PERMIT TO IMPORT OR TRANSFER LIVE BATS

FORM APPROVED
OMB NO. 0920-0199
EXP DATE 01/31/2017

Page 2 of 2

SECTION D – TYPE OF PERMIT AND SHIPMENT INFORMATION
1.  Importation into U.S.
 Transfer within the U.S
2. U.S. port(s) of entry (if known):
3. Size of transport container(s):
5. Method of transport:

 Air

4. Number of bats per container(s):
 Surface

 Other
(Explain:__________________________________________________________)

SECTION E – BIOSAFETY MEASURES FOR FACILITIES AND TECHNICAL PERSONNEL
1. Description of 180-day quarantine laboratory facilities and equipment:

Animal Biosafety level (ABSL) of 180-day quarantine facility (See instructions):
 ABSL1  ABSL2  ABSL3  ABSL4
2. Description of post-quarantine housing:

Biosafety level of post-quarantine facility (See instructions):
 ABSL1  ABSL2  ABSL3  ABSL4
3. Name of attending Veterinarian:

4. Affiliation

5. Address (NOT a post office box)

6. City

9. Telephone

10. FAX

7. State

8. Zip Code

11. E-mail

12. Describe the qualifications and experience of technical personnel handling the bats:

13. Have all personnel that will be working with bats received rabies immunizations?  Yes  No (If no, explain:______________
____________________________________________________________________________________________________________)
I hereby certify that the information submitted in this application is complete and accurate to the best of my knowledge and belief. I agree to comply with
the conditions listed in the application and all restrictions and precautions that may be specified in the permit, in addition to all applicable regulations
which govern this transfer. I understand that failure to comply with the importation requirements may subject me to criminal penalties pursuant to 42
U.S.C. 271. I understand that any false statement made in this application may subject me to criminal penalties pursuant to 18 U.S.C. 1001.

SECTION F – SIGNATURE OF PERMITTEE
1. APPLICANT (Print Name)

2. SIGNATURE

3. TITLE

4. DEGREE(S)

5. DATE SIGNED
(MM/DD/YYYY)

Public recording burden of this collection of information is estimated to average 20 minutes 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. An agency may
not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to
CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0199)
CDC 0.1345
REV. 01/14