VS 17-139 Certificate for Importing Sheep and Goat Semen from Cana

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 OMB control numbers for this information collection is 0579-0040. The time
required to complete this 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
VETERINARY SERVICES

OMB APPROVED
0579-0040
EXP.: XX/XXXX

CERTIFICATE FOR IMPORTING SHEEP AND GOAT
SEMEN FROM CANADA

NOTE: Completion of this Certification does not guarantee issuance of a permit. As used herein, “herd” is defined as “any group of animals maintained on common

ground for any purpose, or two or more groups of animals under common ownership or supervision, which are geographically separated, but among which there is
an interchange or movement of animals without regard to health status” and “animals” is defined as “cattle, sheep, goats, and other ruminants..” For semen, you
are certifying to the background of the sire.

1. I CERTIFY that I have direct knowledge of the sheep and/or goat semen offered for importation into the United States from
Canada by:
NAME OF EXPORTER:
2. LAST ADDRESS OF DONOR ANIMAL(S) LOCATION:
3. NAME OF OWNER (OF DONOR ANIMAL(S)):

4. PROVIDE REASON OR CHECK “NOT APPLICABLE”:

Not Applicable

The donor animal(s) has/have never been outside Canada except:

5. DATE OF SHIPMENT:

6. METHOD OF SHIPMENT:

Canadian border port (Land)
Port of entry (Air)
7. SHIPPED TO (U.S. address must be enrolled in Voluntary Scrapie Flock Certification Program (VSFCP) with premise and flock IDs):
8. SELECT THE APPROPRIATE STATEMENT REGARDING THE SEMEN SHIPMENT:
I CERTIFY, within the last 5 years, there have been no animal(s), semen, or embryo(s) imported from a country other

than the United States into any herd where donor sheep or goats of the semen offered for importation then resided.

I am unable to CERTIFY to the above statement. Provide the reason, indicating the date(s) of importation, the exporting

country(s), the quantity, and the type(s) (i.e., semen, embryo, and/or common name of animal):

I CERTIFY all information regarding the importation into Canada of animals or germplasm can be verified by Agriculture and
Agri-Food Canada. If not, specify the reason:

I CERTIFY the information contained herein is true to the best of my knowledge and belief. A false statement on any part of
this Certification may result in my punishment by fine and/or imprisonment (18.U.S.C.)

EXPORTER OR EXPORTER AGENT (Print Name)
VS Form 17-139

JULY 2017

EXPORTER OR EXPORTER AGENT (Signature)