VS 11-1A Application for Enrollment in the Federal Chronic Wastin

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 0579-0189. 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 maintain the data needed, and completing
and reviewing the collection of information.

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

OMB Approved
0579-0189
EXP.: XX/XXXX

APPLICATION FOR ENROLLMENT IN THE FEDERAL CHRONIC WASTING DISEASE
VOLUNTARY HERD CERTIFICATION PROGRAM FOR FARMED AND CAPTIVE
CERVIDS CONTINUATION SHEET
Owner Information

1. Owner’s Name:
2. Mailing Address:
3. City:

4. County:

5. State:

6. ZIP Code:

7. Business Phone Number:

8. Cell Phone Number:

9. Business Fax Number:

13. City:

14. County:

15. State:

17. Business Phone Number:

18. Cell Phone Number:

19. Business Fax Number:

23. City:

24. County:

25. State:

27. Business Phone Number:

28. Cell Phone Number:

29. Business Fax Number:

10. Email Address:
11. Owner’s Name:
12. Mailing Address:
16. ZIP Code:

20. Email Address:
21. Owner’s Name:
22. Mailing Address:
26. ZIP Code:

30. Email Address:
Facility Information
31. Facility Name:
32. * Premises Identification Number (PIN):
33. Address:
34. City:

35. County:

36. State:

37. ZIP Code:

38. Business Phone Number:

39. Cell Phone Number:

40. Business Fax Number:

45. City:

46. County:

47. State:

49. Business Phone Number:

50. Cell Phone Number:

51. Business Fax Number:

56. City:

57. County:

58. State:

60. Business Phone Number:

61. Cell Phone Number:

62. Business Fax Number:

41. Business Email Address:
42. Facility Name:
43. * Premises Identification Number (PIN):
44. Address:
48. ZIP Code:

52. Business Email Address:
53. Facility Name:
54. * Premises Identification Number (PIN):
55. Address:

63. Business Email Address:
VS Form 11-1 A
AUG 2012

59. ZIP Code: