APHIS 7011A Application for New Registration

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 INFORMATION COLLECTION IS 05790036. THE TIME REQUIRED TO COMPLETE THE 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.

USDA USE ONLY

OMB APPROVED 0579-0036
EXP.: XX/XXXX

APPLICANT SHOULD SEND COMPLETED FORM TO THIS ADDRESS:

CERTIFICATE NO./CUSTOMER NO:

RENEWAL DATE:

UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE

APPLICATION FOR NEW REGISTRATION
(TYPE OR PRINT)

EVERY RESEARCH FACILITY, CARRIER, AND INTERMEDIATE HANDLER NOT REQUIRED TO BE LICENSED UNDER SECTION 3 OF THE ANIMAL WELFARE ACT, SHALL REGISTER WITH THE USDA
(7 U.S.C. 2136).
1.
TYPE OF REGISTRATION REQUESTED:
☐ INTERMEDIATE HANDLER ☐ CARRIER ☐ RESEARCH FACILITY
2.
TYPE OF ORGANIZATION:
☐ INDIVIDUAL ☐ CORPORATION

☐ PARTNERSHIP

☐ FEDERAL RESEARCH FACILITY ☐ AGRICULTURAL RESEARCH FACILITY ☐ VETERANS’ ADMINISTRATION

☐ UNIVERSITY

☐ LLC

☐ SOLE PROPRIETOR

☐ TRUSTS

☐ OTHER____________________________

TYPE OF PUBLIC: (Select one)
☐ STATE, LOCAL, TRIBAL GOVERNMENT ☐ BUSINESS OR OTHER FOR-PROFIT ☐ NOT-FOR-PROFIT INSTITUTION ☐ FARM ☐ FOREIGN OR DOMESTIC FEDERAL GOVERNMENT
☐ INDIVIDUAL OR HOUSEHOLD
3.

4.

NAME OF REGISTRANT AND MAILING ADDRESS: (SEE INSTRUCTIONS)

9.
ALL BUSINESS NAMES AND LOCATION ADDRESSES HOUSING ANIMALS:
INCLUDE DIRECTIONS TO EACH LOCATION (P.O. BOX NOT ACCEPTABLE)
☐ CHECK THIS BOX IF ADDITIONAL LOCATIONS ARE LISTED ON AN ADDITIONAL SHEET.

5.

COUNTY:

10.

COUNTY:

6.

TELEPHONE:

11.

TELEPHONE NUMBER AT THIS LOCATION:

7.

☐ RESIDENTIAL ADDRESS

12.

OPTIMAL HOURS FOR INSPECTION AT THIS LOCATION: (DAYS OF THE WEEK AND TIMES OF

8.

EMAIL:

13.

WEBSITE:

☐ NON-RESIDENTIAL ADDRESS

DAY)

14. IF INDIVIDUAL, IDENTIFY EACH OWNER, IF PARTNERSHIP IDENTIFY EACH PARTNER OR OFFICER, IF CORPORATION, IDENTIFY PRINCIPAL OFFICERS FOR RESEARCH FACILITIES.
INCLUDE THE INSTITUTIONAL OFFICIAL.
☐ CHECK THIS BOX IF ADDITIONAL PERSONS ARE LISTED ON AN ADDITIONAL SHEET.
NAME

TITLE

ADDRESS (FULL ADDRESS INCLUDING ZIP CODE)

CERTIFICATION
I HEREBY REGISTER AS A RESEARCH FACILITY, CARRIER, OR INTERMEDIATE HANDLER UNDER THE ANIMAL WELFARE ACT, 7 U.S.C. 2131 ET SEQ. AND I CERTIFY THAT THE
INFORMATION PROVIDED HEREIN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I HEREBY ACKNOWLEDGE RECEIPT OF AND AGREE TO COMPLY WITH ALL THE
REGULATIONS AND STANDARDS CONTAINED IN 9 CFR, SUBPART A, PARTS 1, 2 AND 3. I CERTIFY THAT ALL LISTED PERSONS ARE 18 YEARS OF AGE OR OLDER.
15.

SIGNATURE

APHIS FORM 7011 A
OCT 2018

16.

NAME AND TITLE (TYPE OR PRINT)

17.

DATE SIGNED

Privacy Act Notice
Authority: The Animal Welfare Act (AWA), 7 U.S.C. 2131 et seq., and the regulations issued thereunder, 9 CFR parts 1 through 4; and the Horse
Protection Act (HPA), 15 U.S.C. 1821 et seq., and the regulations issued thereunder, 9 CFR parts 11 and 12.
Purpose: This system supports APHIS’ administrative activities and enforcement of the AWA and HPA.
Routine Uses:
In addition to those disclosures generally permitted under 5 U.S.C. 552a (b) of the Privacy Act, records maintained in the system may be disclosed outside
USDA as follows:
(1) APHIS may disclose the name, city, State, license or registration type and/or status, or change of a license or registrant to any person pursuant to 9 CFR
2.38(c) and 2.127;
(2) APHIS may disclose annual reports submitted to APHIS by licensees and research facilities to any person pursuant to 9 CFR 2.7 and 2.36;
(3) APHIS may disclose inspection reports and other regulatory correspondence issued to licensees and registrants [from the agency] to any attending
veterinarian in order to carry out duties under the AWA pursuant to 9 CFR 2.33 and 2.40;
(4) APHIS may disclose the name, telephone number and other contact information, location, inspection reports, and regulatory and other correspondence
of licensees, registrants, permitees, and applicants for the same, to appropriate Federal, foreign, State, local, Tribal, or other public authority agencies or
officials, in order to carry out duties under the AWA or State, local, Tribal or other public authority on the same subject pursuant to 7 U.S.C. 2145(b);
(5) APHIS may disclose inspection reports of licensees and registrants, and permit status, to any pet store or other entity that is required under State, local,
Tribal, or other public authority to verify a licensee, registrant, or permitee’s compliance with the AWA;
(6) APHIS may disclose information to the National Academies of Sciences, Engineering, and Medicine, and any other research institution engaged or
approved by the Department, to the extent APHIS deems the disclosure necessary to complete research and/or compile a report in furtherance of the
Department’s mission;
(7) APHIS may disclose final adjudicatory AWA and HPA decisions or orders by an appropriate authority to any person;
(8) APHIS may disclose to any person the name, city, and State or other information to the extent necessary for proper identification of persons (referred to
as “Designated Qualified Persons” or “DQPs”) that are or have been qualified to detect and diagnose a horse that is sore or otherwise inspect horses for
purposes of enforcing the HPA and of horse industry organizations or associations (referred to as “HIOs”) that have currently or have had in the past DQP
programs certified by the USDA;
(9) APHIS may disclose to any regulated horse owner, HIO, and other entities responsible for licensure or required to verify compliance with the HPA, HPA
inspection findings and regulatory and other correspondence issued to persons or entities regulated under the HPA;
(10) APHIS may disclose to any person the name, city, and State or other information to the extent necessary for proper identification of any person or entity
who has been disqualified, suspended, and/or otherwise prohibited from showing or exhibiting any horse, or judging or managing any horse show, horse
exhibition, horse sale, or horse auction under the HPA and the terms of such action;
(11) APHIS may disclose to any person the name, city, and State or other information to the extent necessary for proper identification of any regulated
individual or entity whose license or permit has been suspended, revoked, expired, terminated, or denied under the AWA and the terms of such action;
(12) APHIS may disclose to appropriate law enforcement agencies, entities, and persons, whether Federal, foreign, State, local, or Tribal, or other public
authority responsible for enforcing, investigating, or prosecuting an alleged violation or a violation of law or charged with enforcing, implementing, or
complying with a statute, rule, regulation, or order issued pursuant thereto, when a record in this system on its face, or in conjunction with other records,
indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether arising by general statute or particular program
statute, or by regulation, rule, or court order issued pursuant thereto, if the information disclosed is relevant to any enforcement, regulatory, investigative, or
prosecutive responsibility of the receiving entity;
(13) APHIS may disclose to the Department of Justice when the agency, or any component thereof, or any employee of the agency in his or her official
capacity, or any employee of the agency in his or her individual capacity where the Department of Justice has agreed to represent the employee, or the
United States, in litigation, where the agency determines that litigation is likely to affect the agency or any of its components, is a party to litigation or has an
interest in such litigation, and the use of such records by the Department of Justice is deemed by the agency to be relevant and necessary to the litigation;
provided, however, that in each case, the agency determines that disclosure of the records to the Department of Justice is a use of the information contained
in the records that is compatible with the purpose for which the records were collected;
(14) APHIS may disclose information in this system of records to a court or adjudicative body in administrative, civil, or criminal proceedings when: (a) The
agency or any component thereof; or (b) any employee of the agency in his or her official capacity; or (c) any employee of the agency in his or her individual
capacity where the agency has agreed to represent the employee; or (d) the United States Government, is a party to litigation or has an interest in such
litigation, and by careful review, the agency determines that the records are to be for a purpose that is compatible with the purpose for which the agency
collected the records;
(15) APHIS may disclose information from this system of records to appropriate agencies, entities, and persons when: (a) USDA suspects or has confirmed
that there has been a breach of the system of records; (b) USDA has determined that as a result of the suspected or confirmed breach there is a risk of harm
to individuals, USDA (including its information systems, programs, and operations), the Federal Government, or national security; and (c) the disclosure
made to such agencies, entities, and persons is reasonably necessary to assist in connection with USDA’s efforts to respond to the suspected or confirmed
compromise and prevent, minimize, or remedy such harm;
(16) APHIS may disclose information from this system of records to another Federal agency or Federal entity, when the USDA determines that information
from this system of records is reasonably necessary to assist the recipient agency or entity in (a) responding to a suspected or confirmed breach or (b)
preventing, minimizing, or remedying the risk of harm to individuals, the recipient agency or entity (including its information systems, programs, and
operations), the Federal Government, or national security, resulting from a suspected or confirmed breach;
(17) APHIS may disclose information in this system of records to USDA contractors and other parties engaged to assist in administering the program,
analyzing data, developing information management systems, processing Freedom of Information Act requests, and conducting audits. Such contractors
and other parties will be bound by the nondisclosure provisions of the Privacy Act;
(18) APHIS may disclose information in this system of records to USDA contractors, partner agency employees or contractors, or private industry employed
to identify patterns, trends, or anomalies indicative of fraud, waste, or abuse;
(19) APHIS may disclose information in this system of records to a Congressional office from the record of an individual in response to any inquiry from that
Congressional office made at the written request of the individual to whom the record pertains;
(20) APHIS may disclose information in this system of records to the National Archives and Records Administration or to the General Services
Administration for records management activities conducted under 44 U.S.C. 2904 and 2906; and
(21) APHIS may disclose information in this system of records to the Treasury Department as necessary to carry out any and all functions within their
jurisdiction, including but not limited to, processing payments, fees, collections, penalties, and offsets.
Disclosure: Furnishing this information is voluntary; however, failure to furnish this information may impede you’re a ability to comply with the requirements
of the Animal Welfare Act, regulations, and standards.