VS Form 9-22 Application For U.S. Avian Influenza Clean Compartment C

Clear Form
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valid OMB control number. The valid OMB control number of this information collection is 0579-0007. 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 of information.

OMB Approved
0579-0007
EXP: XX/XXXX

Application For U.S. Avian Influenza
Clean Compartment Component Removal

Instructions: Applicants please complete Sections A and B and certify with signature. Then send the form to the OSA
which completes Section C and signs. OSA returns form to NPIP.

A: BACKGROUND INFORMATION. To be completed by company seeking removal of a
component within a certified compartment. Please note that once a component has been successfully
removed, it will no longer function as part of the compartment. Adding the component back to the
compartment will require recertification using Application Form B.

Name of Company
Company Mailing Address
Name of Contact
Telephone Number
Alternate Telephone Number
Fax Number
Email Address
NPIP Classification

U.S. AI Clean 

U.S. H5/H7 AI Clean 

Breed/Type of Poultry
NPIP Classification Seeking
Compartment Mailing Address
Compartment Location (List States
Involved)
Name of Compartment
Type of Components (F, M, H, and E)
to add within Compartment

Farm  Feedmill  Hatchery  Egg Depot 

B. Reason for Removal. To be completed by company seeking component removal. To be eligible
for removal as a compartment, a justification for removal and a detailed description of how the
component removal will affect the rest of the compartment must be provided. Please use the box below.
(Note: If component removal will not affect the compartment, please check here .)

VS FORM 9-22
OCT 2018

C. Verification. To be completed by each Official State Agency. Please place a check mark by the
answer that applies.
YES

NO

Is the component of the compartment part of a company that is a participant in
the U.S. H5/H7 Avian Influenza Clean Compartment program and in good
standing with the NPIP: U.S. H5/H7 Avian Influenza Clean Program for Turkey
Breeding Flocks?
Is the component of the compartment part of a company that is a participant in
the U.S. Avian Influenza Clean Compartment program and in good standing with
the NPIP: U.S. Avian Influenza Clean Program for Primary Egg-Type Chicken
Breeding Flocks?
Is the component of the compartment part of a company that is a participant in
the U.S. Avian Influenza Clean Compartment program and in good standing with
the NPIP: U.S. Avian Influenza Clean Program for Primary Meat-Type Chicken
Breeding Flocks?
Within the company, are all other operations certified as components within
the registered compartment part of the U.S. Avian Influenza Clean
Compartment program (for egg-type chicken breeding flocks and meat-type
chicken breeding flocks) or the U.S. H5/H7 Avian Influenza Clean Compartment
(for turkey breeding flocks) and located in a State which has an APHIS-approved
Initial State Response and Containment Plan?

CERTIFICATION OF OFFICIAL STATE AGENCY or AGENCIES
I DO HEREBY CERTIFY THAT ALL STATEMENTS MADE BY ME IN THIS APPLICATION ARE TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF. FURTHER, I UNDERSTAND THAT
IN THE EVENT I HAVE KNOWINGLY AND WILLFULLY MADE ANY FALSE STATEMENTS, I WILL BE LIABLE
FOR PUNISHMENT IN ACCORDANCE WITH ALL APPLICABLE LAWS AND STATUTES.
State:

State:

Signature:

Signature:

Date:

Date:

State:

State:

Signature:

Signature:

Date:

Date:

CERTIFICATION OF APPLICANT
I DO HEREBY CERTIFY THAT ALL STATEMENTS MADE BY ME IN THIS APPLICATION ARE TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF, AND I HAVE OBTAINED ALL
NECESSARY OFFICIAL STATE AGENCIES’ CERTIFICATION IN C ABOVE. FURTHER, I UNDERSTAND THAT IN
THE EVENT I HAVE KNOWINGLY AND WILLFULLY MADE ANY FALSE STATEMENTS, I WILL BE LIABLE FOR
PUNISHMENT IN ACCORDANCE WITH ALL APPLICABLE LAWS AND STATUTES. FURTHER, I CERTIFY THAT
BY COMPLETION OF THIS FORM, THIS COMPONENT OF THE COMPARTMENT WILL HAVE TO GO
THROUGH THE RE- APPLICATION PROCESS TO BE FORMALLY RECOGNIZED AS A CERTIFIED COMPONENT.
Signature:
Date:

Application
A complete application must be sent to:
The National Poultry
Improvement Plan
1506 Klondike Road,
Suite 101
USDA-APHIS-VS
Conyers, GA 30094
[email protected] with
cc to [email protected]

For Department Use Only
Date
Received:

Reviewer:

Check Here if Approval Granted for Removal of Component: 
Check Here if Approval Denied for Removal of Component:
Signature:
If Denied, List Reasons:

