Form VS 16-3 VS 16-3 Application for Permit To: Import or Transport Controlle

Failure to supply all applicable information can delay the processing of this application.

No controlled material, organisms, or
vectors may be imported or moved
interstate unless the data requested
on this form is furnished and certified
(9 CFR Parts 94, 95, and 122).

PLEASE TYPE OR PRINT CLEARLY.

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 numbers of these collections of information are 0579-0040, 0579-0145, 0579-0245, and 0579-0393. The
estimated time to complete this information collection is estimated to average between .5 and 1.6 hours per
response, including the time for reviewing 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
National Center for Import-Export, Products Program
4700 River Road, Unit 40
Riverdale, MD 20737-1231

APPLICATION FOR PERMIT TO:
IMPORT OR TRANSPORT CONTROLLED MATERIAL OR
ORGANISMS OR VECTORS
3. IMPORTER: (Name, organization, complete address, telephone and fax numbers
of individual who will receive and be responsible for the imported material)

OMB Approved

0579-0040, 0579-0144,
0579-0245, and 0579-0393

1. MODE OF TRANSPORTATION (Please ”X”):
AIR

SEA

LAND

2. UNITED STATES PORTS OF ENTRY

4. SHIPPER(s): (Name and Address of producer/shipper)

5. DESCRIBE THE MATERIAL TO BE IMPORTED (Provide the following information, as applicable: Animal species and tissue of origin of animal product, country of origin of
the animal for which raw animal product was sourced, processing country, recombinant system and genetic inserts, antibody immunogenic stabilizers, nutritive factors of
animal origin in media.) (COMPLETE VS FORM 16-7 for cell culture and their products.)

6. QUANTITY, FREQUENCY OF IMPORTATION, AND EXPECTED COMPLETION DATE (Estimate)

7. PROPOSED USE OF MATERIAL AND DERIVATIVES (Also, for animal pathogens or vectors, describe facilities/biosafety procedures)

8. IF FOR USE IN ANIMALS, SPECIFY THE ANIMAL SPECIES

9. TREATMENT OF MATERIAL PRIOR TO IMPORTATION INTO THE UNITED STATES (Processing/purification methods, including time at specific temperatures, pH, other
treatments, disease safeguards, etc.)

10. METHOD OF FINAL DISPOSITION OF IMPORTED MATERIAL AND DERIVATIVES

I CERTIFY AS AUTHORIZED BY THE COMPANY/INSTITUTION THAT I REPRESENT, THAT THIS MATERIAL WILL BE USED IN ACCORDANCE WITH ALL
RESTRICTIONS AND PRECAUTIONS AS MAY BE SPECIFIED IN THE PERMIT.
11. SIGNATURE OF APPLICANT

13. DATE

VS FORM 16-3
JUL 2012

12. TYPED NAME AND TITLE

14. APHIS USER FEE CREDIT ACCOUNT NO. OR METHOD OF USER FEE PAYMENT (for VISA or MasterCard include number and
expiration date).