WS 12 Addendum to a Work Initiation Document

National Management Information System (Wildlife Service)

WS FORM 12 ADDENDUM OCT 2017 SECURE

State, Local, Tribal Governments

OMB: 0579-0335

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displays a valid OMB control number. The valid OMB control number for this information collection is 0579-0335. The time required to complete this information collection
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UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
WILDLIFE SERVICES

OMB Approved
0579-0335
EXP: XX/XXXX

ADDENDUM TO A
WORK INITIATION DOCUMENT

INSTRUCTIONS
1. In Items 1-3, enter the number of the Work Initiation Document for which this addendum is completed, as well as the agreement name and county located.
2. In Items 4-6, enter the Cooperator’s name and telephone number, and the date the addendum is prepared.
3. In Items 7 and 8, enter the additional species that will be addressed and additional components to be used.
4. In Items 9 and 10, enter the Cooperator’s and WS Employee’s signatures and dates signed.
5. Attach to and distribute with the WS Form 12A or 12B work initiation document.
1. WORK INITIATION DOCUMENT NO.

2. AGREEMENT NAME

3. COUNTY

4. COOPERATOR NAME

5. TELEPHONE NUMBER

6. DATE (MM DD YYYY)

7. ADDITIONAL TARGETED SPECIES
K.

S.

AA.

L.

T.

BB.

M.

U.

CC.

N.

V.

DD.

O.

W.

EE.

P.

X.

FF.

Q.

Y.

GG.

R.

Z.

HH.

G.

O.

W.

H.

P.

X.

I.

Q.

Y.

J.

R.

Z.

K.

S.

AA.

L.

T.

BB.

M.

U.

CC.

N.

V.

DD.

8. ADDITIONAL COMPONENTS TO BE USED

9A. LANDOWNER, LESSEE, OR ADMINISTRATOR SIGNATURE

9B. DATE

10A. APHIS WS REPRESENTATIVE SIGNATURE

10B. DATE

WS FORM 12 ADDENDUM
OCT 2017


File Typeapplication/pdf
File TitleAccording to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond
AuthorGovernment User
File Modified2019-06-11
File Created2017-08-15

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