Vs 1-38 Application For Permit To Move Slaughter Swine From Orig

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 number for this information collection is 0579-0065. The time required to complete this information collection is
estimated to average between 4 and 6 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
1A. FACILITY NAME

OMB Approved
0579-0065
Exp.: XX/XXXX

APPLICATION FOR PERMIT TO MOVE SLAUGHTER
SWINE FROM ORIGINATING SLAUGHTER FACILITIES
TO APPROVED DESTINATION FACILITIES

APPROVED DESTINATION FACILITIES
1B. FACILITY ADDRESS

1C. CONTACT PERSON

1D. TELEPHONE

2A. FACILITY NAME

2B. FACILITY ADDRESS

2C. CONTACT PERSON

2D. TELEPHONE

3A. FACILITY NAME

3B. FACILITY ADDRESS

3C. CONTACT PERSON

3D. TELEPHONE

4A. FACILITY NAME

4B. FACILITY ADDRESS

4C. CONTACT PERSON

4D. TELEPHONE

The applicant agrees to abide by all terms in this agreement. If approved destination facilities should
change, the applicant will inform Assistant Directors’ office of both the originating State and the destination
State for approval of additions or deletions to the list of approved facilities prior to changing the
destination(s) of reshipped slaughter swine.
6. APPLICANT
6A. NAME (Printed)
6B. SINGATURE

7A. NAME (Printed)

7C. ORGINATING STATE

8A. NAME (Printed)

8C. DESTINATION STATE

9A. NAME (Printed)

9C. DESTINATION STATE

VS FORM 1-38
MAY 2017

7. ASSISTANT DIRECTOR’S ORGINATING STATE
7B. SINGATURE

7D. DATE

8. ASSISTANT DIRECTOR’S DESTINATION STATE
8B. SINGATURE

8D. DATE

9. STATE VETERINARIAN DESTINATION STATE
9B. SINGATURE

9D. DATE

5. THE PERMIT, IF APPROVED IS
VALID FOR THREE YEARS FROM:

6C. DATE