Form VS 1-63 VS 1-63 Tribal Location Identification System Implementation Req

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 collection is 0579-0327. The time required to complete this information collection is estimated to average 1 hour
per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
information.

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

OMB APPROVED
0579-0327
EXP.: XX/XX/XXXX

TRIBAL LOCATION IDENTIFICATION SYSTEM IMPLEMENTATION
REQUEST

TRIBE:

Who will function as Animal Traceability Administrator for the tribe? This person is responsible for coordinating the animal traceability activities for the tribe including outreach,
education, premises data collection, premises registration, and premises contact information updates. The Animal Traceability Administrator has the access level to perform all data
administration functions for the tribe including data entry, data editing, data viewing, data searching, account and premises creation and inactivation, creating new users and contacts,
and assigning of access privileges. This is the person with whom USDA communicates on the premises registration issues.
NAME:
ADDRESS:

CITY/STATE:

PHONE NUMBER:

FAX NUMBER:

ZIP CODE:

EMAIL:

After reading the list of options, decide how your tribe would like to participate. Not every tribe needs to submit a request at this time. Submit this request form only when your tribe
is ready to proceed with premises registration.
Please indicate your request by checking one of the boxes below.
Our tribe would like to implement the Tribal Premises Registration System funded by USDA. We have a dedicated database administrator and sufficient personnel for data
entry and premises exception requirements.

Our tribe would like to implement the Tribal Premises Registration System funded by USDA. We do not have a dedicated database administrator or sufficient personnel for
data entry. We would like to use the following organization/company to provide these resources as an Authorized Agent of our future.
ORGANIZATION NAME:

Our tribe would like to use the Standard Premises Registration System funded by USDA that is used by the State in which the tribe is located. We will work with the State
to register our premises.

Our tribe would like to utilize a premises registration system we have developed for ourselves with our own resources (not Federal funds). We request that USDA evaluate
our system to ensure that it is compliant with the standards of animal traceability activities. If our system meets the standards, we further request that USDA provide
interfaces to the National Premises Number Allocator and the National Premises Information Repository.

Our tribe would like to utilize the premises registration system provided by a private company with which we have a memorandum of understanding or contract using our
own resources (not Federal funds). We request that USDA evaluate the system to ensure that it is compliant with the standards of the animal traceability system. If the
system meets the standards, we further request that USDA provide interfaces to the National Premises Number Allocator and the National Premises Information
Repository.
COMPANY NAME:

Please send this request form and address any questions or comments to:
John F. Wiemers
USDA, APHIS, VS
2100 S. Lake Storey Road
Galesburg, IL 61401

Phone: 309-344-1942
Fax: 309-344-1489
[email protected]

Certification of Authorized Tribal Representative: I hereby certify that this request is authorized according to the laws governing our tribe.
NAME:

TITLE:
SIGNATURE:

PHONE NUMBER:

VS Form 1-63
APR 2014

DATE: