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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 0579-0328. The time required to complete this information collection
is estimated to average .5 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.
0579-0328
EXP. 3/31/2020
This certificate is authorized by law (21 U.S.C. 112). While you are not required to respond, no health certificate can be validated unless the data required are provided.
UNITED STATES DEPARTMENT OF AGRICULTURE
1. DATE OF SHIPMENT
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
No.
CERTIFICATE FOR POULTRY OR HATCHING EGGS FOR EXPORT
2. NAME AND ADDRESS OF EXPORTER (include ZIP Code)
3. NAME AND ADDRESS OF IMPORTER
FIPS COUNTRY CODE (for USDA use only)
10. NPIP CLASSIFICATION-U.S.
("X" or check)
Other
Meat-Type
Eggs-Type
Primary
Breeding
Stock
Other
Meat-Type
Multiplier
Breeding
Stock
Eggs-Type
Other
Meat-Type
Eggs-Type
Males
9. NPIP APPROVAL NUMBER
8.TYPE (intended use) ("X" or check)
Commercial
Production
Stock
Females
Straight-run
7. SEX
("X" or check)
Other
Poults
Chicks
5.VARIETY, STRAIN, OR
TRADE NAME
Turkey Eggs
4.QUANTITY/UNIT
(Eggs-Dozen)
(Poultry-Number)
Chicken Eggs
6. PRODUCT
("X" or check)
PullorumTyphoid
Clean`
M.
Gallisepticum
Clean
M.
Meleagridis
Clean
Sanitation
Monitored
FIPS STATE CODE (for USDA use only)
Other
(specify)
11. TOTAL NUMBER OF UNITS CERTIFIED FOR EXPORT
12. CHECK APPROPRIATE CERTIFICATION BELOW (A OR B)
A. Certificate for Hatching Eggs and Newly Hatched Poultry, which have not been fed or watered. This is to certify that: (1) the flock or flocks and the hatchery or
hatcheries from which the above-described hatching eggs or newly hatched poultry originated were inspected by me or another accredited veterinarian within 30
days prior to shipment of above hatching eggs or setting of eggs for above shipment of day old chicks and found free from evidence of communicable diseases
and insofar as can be determined have not been exposed to Newcastle disease, fowl plague, fowl typhoid, ornithosis, and pullorum disease; (2) during the usual
routine inspection of the flock or flocks there was no visible evidence of communicable diseases observed on the inspection dates listed in item 13 below; (3) the
National Poultry Improvement Plan classification is as indicated in item 9 above, and (4) the prospective exporter has been advised that the hatching eggs must
be clean and that the shipment must be made in new, clean containers.
B. Certificate for Poultry other than Newly Hatched Poultry Specified in Certificate A. This is to certify that: (1) on this date all poultry shown in item 5 above,
including all other poultry maintained in the flock, were inspected by me on the premises of origin within the past 30 days and found free from evidence of
infectious and contagious diseases and insofar as can be determined have not been exposed to Newcastle disease, fowl plague, fowl typhoid, ornithosis and
pullorum disease; and (2) the prospective exporter has been advised that shipment must be made in new containers or clean containers which have been
properly cleaned and disinfected.
13. REMARKS OR ADDITIONAL INFORMATION (if needed)
14. TYPED NAME OF ISSUING VETERINARIAN
15. SIGNATURE OF ISSUING VETERINARIAN
16. STATUS
17. DATE ISSUED
1. State
2. Federal
3. Accredited
18. SIGNATURE OF ENDORSING FEDERAL VETERINARIAN (if required)
Clear FormCLEAR FORM
DA
YR
19. DATE ENDORSED
MO
USDA VETERINARY SEAL (if required)
VS FORM 17-6
JUL 2014
MO
DA
YR
VS FORM 17-6 (REVERSE)
CODES
FIPS STATE CODES
01 – Alabama
18 – Indiana
31 – Nebraska
02 – Alaska
19 – Iowa
32 – Nevada
44 – Rhode Island
45 – South Carolina
04 – Arizona
20 – Kansas
33 – New Hampshire
46 – South Dakota
05 – Arkansas
21 – Kentucky
34 – New Jersey
47 – Tennessee
06 – California
22 – Louisiana
35 – New Mexico
48 – Texas
08 – Colorado
23 – Maine
36 – New York
49 – Utah
09 – Connecticut
24 – Maryland
37 – North Carolina
50 – Vermont
51 – Virginia
10 – Delaware
25 – Massachusetts
38 – North Dakota
11 – District of Columbia
26 – Michigan
39 – Ohio
52 – Virgin Island
12 – Florida
27 – Minnesota
40 – Oklahoma
53 – Washington
13 – Georgia
28 – Mississippi
41 – Oregon
54 – West Virginia
15 – Hawaii
29 – Missouri
42 – Pennsylvania
55 – Wisconsin
16 – Idaho
30 – Montana
43 – Puerto Rico
56 – Wyoming
17 – Illinois
| File Type | application/pdf |
| File Title | According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it di |
| Author | Government User |
| File Modified | 2019-03-18 |
| File Created | 2013-12-06 |