VS 16-79 ON-Hold Shipment Notification Application

According to the Paperwork Reduction Act of 1995, no persons are 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.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICES
VETERINARY SERVICES

OMB APPROVED
0579-0040
EXP.: XX/XXXX

ON-HOLD SHIPMENT NOTIFICATION
APPLICATION

This form is to be completed by customers that have been subject to an animal products or organism and vectors shipment being
held or in quarantine by the USDA and/or the Department of Homeland Security, Customs and Border Protection (CBP). The on-hold
processing fee associated with this application is non-refundable and does not expedite or guarantee release of shipment. For additional
information contact the Veterinary Services (VS) office at 301-851-3300.
Instructions: Submit the completed packet (application form and supporting documents) to:
Animal Products: Fax to 301-724-8226 or (preferably) by email to [email protected]
Organism and Vectors: Fax to 301-851-2239 or (preferably) by email to [email protected]
The supporting documents listed below MUST accompany this application:
1. Valid Veterinary Services Import Permit or Application for New Permit (if applicable)
2. Airway Bill/Bill of Lading/Courier Tracking Receipt
3. Invoice/Manifest
4. Foreign Government Certification and/or Manufacturers Statement
5. Detailed documents describing the processing the materials have undergone prior to export to the U.S.
6. Copies of correspondence with the port regarding the shipment hold
Emergency Action Notification (EAN) issued:
Yes or
No - If yes, EAN document must be provided. Contact the VS
office BEFORE submitting this form, as the shipment may not be eligible for release.
1. CBP Agriculture Specialist (CBPAS) or USDA Inspector

2. U.S. Importer/Consignee

Name:

Name:

Port City:

Company Name:

Port State:

Address:

Port Phone Number:

Phone Number:

Port Fax Number:

Fax Number:

Email Address:

Email Address:

Name of Product:

3. Description of Material Presently Detained at the Port of Entry
Vessel Name:

Country of Origin:

Tracking Number:

Country of Export:

Container Number:

Date of Arrival:

Flight Information:

Customs Entry Number:

Airway Bill (if applicable):

Courier Name:

Bill of Lading (if applicable):

Identify the animal origin ingredients/components including animal species (cow, sheep, horse, bird) and country of origin:

User Fee Account Number:

4. Payment Method
Credit Card Number:

Expiration Date (mm/yyyy):
Signature:

VS Form 16-79
APR 2017

Date: