VS 17-11 Application for Quarantine Facility for Birds

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 0579-0040. The time required to complete this information collection is estimated to average .5 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.						OMB APPROVED 0579-0040 EXP.: XX/XXXX
A completed application is required for approval of a privately-operated bird quarantine facility. The information is used by USDA-APHIS to take action concerning the required approval (9 CFR 92).
UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE APPLICATION FOR A QUARANTINE FACILITY FOR BIRDS		SEND COMPLETED APPLICATION TO: USDA-APHIS-VS Import/Export Animals and Products Staff 4700 River Road, Unit 39 Riverdale, MD 20737
INSTRUCTIONS: Please type or print. Return one copy of the completed application to the address indicated at right. If you need more space to answer any of the questions, continue on reverse or on a separate sheet. Cite item number.
1. NAME AND ADDRESS OF IMPORTER (Include ZIP Code)		2. ADDRESS WHERE QUARANTINE FACILITY WILL BE LOCATED (If different from item 1)
TELEPHONE NUMBER (Include area code)		TELEPHONE NUMBER (Include area code)
3. NAME, TITLE, AND ADDRESS OF INTENDED OPERATORS, PARTNERS, OFFICERS, DIRECTORS, HOLDERS, OR OWNERS OF 10 PERCENT OR MORE OF VOTING STOCK; AND EMPLOYEES IN A MANAGERIAL OR EXECUTIVE CAPACITY.
A. NAME	B. TITLE			C. ADDRESS (Number, Street, City, and ZIP Code)
4. WATER SOURCE (“X” one) Public Private	5. WASTE DISPOSAL (“X” one or both, as applicable) Sewer Incinerator
6. PLANS FOR PROPOSED FACILITY (Make a drawing of floor plan or attach blueprints of your facility) SHOWING LOCATION FOR: * Bird holding area (s) * Clothes storage and change area(s) * Necropsy room (showing entry and refrigeration) * Equipment storage area(s) * Feed storage area (s) * Entries and exits * Washing area(s) for equipment * Office area(s) * Shower area(s) * Ventilation arrangements ALL OTHER PROVISIONS MUST BE MET AS SPECIFIED IN THE REGULATIONS
CERTIFICATION Application is hereby made for approval of a USDA Approved Quarantine Facility for bird importations. I certify that the information provided herein is true and correct to the best of my knowledge and belief, and agree to comply with the applicable regulations in 9 CFR Part 92.
7. SIGNATURE OF IMPORTER			8. PRINT NAME		9. DATE

VS FORM 17-11 JUL 2009 Edition may be used. All others are obsolete.

NOV 2014