VS 17-140 United States Origin Health Certificate

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 numbers for these information are 0579-0020, 0101 and 0432. The time required to complete this information collection is estimated to average between .5 to 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.
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 requested is provided.
1. CONSIGNOR’S NAME (Last Name, First Name, Middle Initial, or Business Name) 2. CERTIFICATE NUMBER

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

UNITED STATES ORIGIN HEALTH CERTIFICATE

(This document does not replace Certificate of Inspection of Export Animals, VS Form 17-27)
5. U.S. PORT OF EMBARKATION (City and State)
4. DATE ISSUED
6. STATE CODE

9. SEMEN ("X" if yes)

10. NUMBER DOSES OF SEMEN

15. SPECIES ("X" one - use VS Form 17-6 for Poultry)
01 BOVINE
05 EQUINE

02 PORCINE

11. TRANSPORTATION CLASS
1 - Rail

3 - Air

2 - Truck

4 - Ocean

03 OVINE

04 CAPRINE

08 OTHER WILDLIFE - MAMMAL

7. CONSIGNOR'S STREET ADDRESS (Mailing Address)

16. CONSIGNEE'S NAME AND STREET ADDRESS (Mailing Address)

VALID ONLY IF USDA VETERINARY SEAL
APPEARS HERE

MODIFIED ACCREDITED AREA (TB)
18. INDIVIDUAL IDENTIFICATION
(Instructions for Columns A, B, C & D on Reverse)
AGE
B

13. STATE CODE

NEGATIVE TUBERCULIN
READING

SEX
C

BREED
D

BRUCELLOSIS BLOOD SAMPLE
COLLECTED

√
G

DATE
H

VAC
I

1/25
J

1/50
K

DISEASE

DISEASE

DISEASE

TYPE TEST

TYPE TEST

TYPE TEST

DATE
M

DATE
N

DATE
O

1/100
L

CERTIFICATION BY ISSUING VETERINARIAN

This is to certify that the animals identified above were inspected by me on this date and found to be free from evidence of communicable diseases and insofar as can be determined exposure
thereto; the premises of origin are not under Federal or State quarantine because of animal disease; the animals were all negative to the tests shown on the dates indicated. Arrangements
have been made for the animals to be handled in a transporting vehicle that has been cleaned and disinfected since last used for livestock and for movement to the port of embarkation
without exposure to other animals en route, except those meeting these health requirements. The shipment must be accompanied to the port of export with this certificate.
19. DATE ENDORSED 20. NAME OF ISSUING VETERINARIAN (Last Name, First Name, Middle Initial - Type or Print) 21. STATUS
22. TOTAL NUMBER OF ANIMALS
2 Federal
1 State

24. NAME OF ENDORSING FEDERAL VETERINARIAN (Type, Print, or Stamp)

25. SIGNATURE OF ISSUING VETERINARIAN

23. Signature of Endorsing Federal Veterinarian

VS Form 17-140
AUG 2018

ENTER CODE

NEGATIVE RESULTS OF OTHER TESTS

CERTIFIED BRUCELLOSIS
FREE AREA
DATE
F

14. ZIP CODE

DESTINATION COUNTRY

72 HRS

√
E

OF

8. CONSIGNOR'S CITY (or Town)

12. CONSIGNOR'S STATE

48 HRS

ID NO. OR DESCRIPTION
A

3. PAGE NUMBER

1

09 OTHER (Specify)
If more lines are needed below - use VS Form 17-140A.
17. FARM ORIGIN
Owner's Name (Last Name, Two Initials, or Business Name)
Owner's Street Address
City/Town, State Code (FIPS Code on Reverse) and ZIP Code

OMB Approved
0579-0020, 0101,
and 0432

Previous edition may be used.

3 Accredited

(Certified for export or donated
semen) (Include numbers from
all attached VS Forms 17-140A)