Form 3-2274 U.S. Title 50 Certification Form

Form 3-2274 (Rev. 02/2017)
U.S. Fish and Wildlife Service

OMB Control No. 1018-0078
Expiration Date: ##/##/####

U.S. Title 50 Certification Form

(To be filled out by the Aquatic Animal Health Inspector)

I,--����,,.-e-,,----' designated by the Director of the U.S. Fish and Wildlife Service
Ccrt1fymg Official's Name

on-..-,--,.:-,-,-:-----,-,.--,,.,...-,�' as required by Title 50, CFR 16.13, do hereby certify the following:
Date ofMost Recent Certification

1) The fish lot( s) of origin for this shipment of up to a maximum of

List Numbers, Life Stage {Eggs or Fish), and Species for This Shipment That Are Covered t3y This Inspection

were most recently sampled at ----------;s,-::---;.,,_----.----;,:-;.,........,,,--,=----..--,--,-,-__,..------­
s,te of Sample Collection (Name and Address)

on-�-----· Viral assays were performed on these samples at
Date of Sample Collection

Name and Address of Laboratory Conducting the Assays

and completed on _______,.,_���-· Sampling and viral assays were conducted using
Date the Assays Were Completed

methodology described in Title 50 CFR 16.13.
2) Oncorhynchus masou virus (OMV), and the viruses causing viral hemorrhagic septicemia
(VHS), infectious hematopoietic necrosis (IHN), and infectious pancreatic necrosis (IPN) have
not been detected in viral assays of fish lot(s) of origin of eggs or fish.
3) This shipment is scheduled to depart-----;,;,.,...--,,,-.,...,,-,_,....,,._,....-:-=:=-;,e-=--....,,,..,.---,-..,..,..,..--.---­
si1e From Which the Fish Will Be Shipped {Name and Address)

between

= --=

and����--------- via

---D-at-es�,n-d�ica-ll�.n-g T�ime F-ra_m_e�th-e Shipments Will Take Place

Means By Which the Shipment Will Be Made {Include Name of Transport Company and Bill of Lading Numbers, Flight Numbers, Etc. if Known)

crossing into the United States at---------��---�-------- Name of An11c1pated Border Crossing

with the destination of

Name and Address of Recipient

Form 3-2274 (Rev. 02/2017)
U.S. Fish and Wildlife Service

OMB Control No. 1018-0078
Expiration Date: ##/##/####

4) Other information of relevance:

Signature: ___ _____ _________
Name:

Date: -------

------------------

Organization: _______________
Street Address:

---------------

City: ___ _______________
State/Province:

---------------

Zip/Postal Code; Country: __ _________
Telephone: ________________
Fax:

------------------Please provide a copy to the importer and return an original
signed copy to:
U.S. Fish and Wildlife Service
Division of the National Fish Hatchery System
5275 Leesburg Pike
Falls Church, VA 22041
USA
Attn: Title 50 Certification

Form 3-2274 (Rev. 02/2017)
U.S. Fish and Wildlife Service

OMB Control No. 1018-0078
Expiration Date: ##/##/####
NOTICE

In accordance with the Paperwork Reduction Act (44 U.S.C 3501), please be advised that:
1. The gathering of information is authorized by the Lacey Act (18 U.S.C. 42) and Title 50, Part 16, of the Code of Federal
Regulations.
2. Failure to provide all of the requested information is sufficient cause for the U.S. Fish and Wildlife Service to deny your request
for importation of salmonide or their eggs under Title 50, Part 16, of the Code of Federal Regulations.
3. You are not required to respond to a collection of information unless it displays a currently valid OMB Control No.
4. This information collection has been approved by OMB and assigned Control Number 1018-0078.
5. The requested information may be subject to disclosure under the provision of the Freedom of Information Act (5 U.S.C. 552).
The public reporting burden for the information collected on this form is 30 minutes. This burden estimate includes time for
reviewing instructions, gathering data, and completing and reviewing the form. Comments on this form should be directed to the
Information Collection Clearance Officer, Division of Policy, Performance, and Management Programs, U.S. Fish and Wildlife
Service, 5275 Leesburg Pike, MS: BPHC, Falls Church, VA 22041-3803.