WS 17 Pocatello Supply Depot Order Form

Clear Form
OMB Approved
0579-0335
EXP: XX/XXXX

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 0579-0335. The time
required to complete this information collection is estimated to average 6 minutes 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.

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

1. THROUGH (name, address, and phone number of State Director)

POCATELLO SUPPLY DEPOT ORDER FORM
Please furnish in accordance with instructions below the following items, and charge same to my account, payment therefore to be made promptly upon delivery and receipt of invoice.

2. SHIP TO (name and address of consignee)

3. TELEPHONE

4. SELECT ONE

5. VIA

RESIDENCE
BUSINESS
6. INVOICE TO

7. PESTICIDE APPLICATOR LICENSE NUMBER

8. CHARGED TO (show appropriation number, if applicable)

BDPD

FUND

FUNCTIONAL AREA

FUND CENTER

FUNDED PROGRAM

SHC

BOC / COMMITMENT ITEM

9. ITEM
NUMBER

10. DESCRIPTION OF SUPPLIES
(for pesticides, list name and APHIS registration number)

11. QUANTITY

12. SIZE OF
CONTAINERS

13. UNIT
PRICE
AND UNIT

14. AMOUNT

$

15. TOTAL

16. APPROVING WS OFFICIAL NAME

17. TELEPHONE

22. FORM PREPARED BY

18. TITLE

24. TELEPHONE

19. ADDRESS

25. EMAIL

20. APPROVING WS OFFICIAL SIGNATURE

21. DATE

$
23. DATE

FOR SUPPLY DEPOT USE ONLY
INVOICE NUMBER

BILL OF LADING NUMBER

SHIPPED BY

DATE SHIPPED

MAIL OR FAX ORIGINAL TO:

POCATELLO SUPPLY DEPOT
238 E. DILLON STREET, POCATELLO, IDAHO 83201
COMMERCIAL: 208-236-6920
FAX: 208-236-6922
WS FORM 17
NOV 2016

INVOICED BY

(Previous edition is obsolete and may not be used.)

0.00

PRIVACY ACT NOTICE
5 U.S.C. 552a(e)(3) requires that each agency that maintains a system of records provide each individual from whom the agency solicits information with
the following information.
AUTHORITY FOR REQUESTING INFORMATION
7 U.S.C. 8351 to 8353, and 16 U.S.C. 667, authorizes officers, agents, and employees of the United States Department of Agriculture (USDA), Animal
and Plant Health Inspection Service (APHIS), Wildlife Services (WS) to conduct a program of wildlife services and to enter into agreements with States,
local jurisdictions, individuals, and public and private agencies, organizations, and institutions for the purpose of conducting such services.
NATURE OF YOUR DISCLOSURE OF INFORMATION
Disclosure of information solicited by USDA, APHIS, Wildlife Services is voluntary.
PRINCIPLE PURPOSE FOR WHICH THE INFORMATION IS SOLICITED
Information is solicited from you for the purpose of executing and implementing agreements for control of wildlife damage.
ROUTINE USES WHICH MAY BE MADE OF THE INFORMATION
(1) To cooperative Federal, State, Tribal, and local government officials, employees, or contractors and other parties as necessary to carry out the
program; and other parties engaged to assist in administering the program. Such contractors and other parties will be bound by the nondisclosure
provisions of the Privacy Act. This routine use assists the agency in carrying out the program, and thus is compatible with the purpose for which the
records are created and maintained;
(2) To the appropriate agency, whether Federal, State, local, Tribal, or foreign, charged with responsibility of investigating or prosecuting a violation of

law or of enforcing, implementing, or complying with a statute, rule, regulation, or order issued pursuant thereto, of any record within this system when
information available indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and either arising by general statute
or particular program statute, or by rule, regulation, or court order issued pursuant thereto;
(3) 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;
(4) For use in a proceeding before a court or adjudicative body before which the agency is authorized to appear, 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 agency
has agreed to represent the employee, or the United States, 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 agency determines that use of such records is relevant and necessary to
the litigation; provided, however, that in each case, the agency determines that disclosure of the records to the court is a use of the information
contained in the records that is compatible with the purpose for which the records were collected;
(5) To appropriate agencies, entities, and persons when the agency suspects or has confirmed that the security or confidentiality of information in the

system of records has been compromised; the agency has determined that as a result of the suspected or confirmed compromise, there is a risk of harm
to economic or property interests, a risk of identity theft or fraud, or a risk of harm to the security of integrity of this system or other systems or programs
(whether maintained by the agency or another agency or entity) that rely upon the compromised information; and the disclosure made to such agencies,
entities, and persons is reasonably necessary to assist in connection with the agency’s efforts to respond to the suspected or confirmed compromise and
prevent, minimize, or remedy such harm;
(6) To USDA contractors, partner agency employee or contractors, or private industry employed to identify patterns, trends, or anomalies indicative of

fraud, waste, or abuse;
(7) To land management agencies, such as the Bureau of Land Management and the U.S. Fish and Wildlife Service, relating to wildlife damage on
grazing allotments;
(8) To consumer reporting agencies in accordance with 31 U.S.C. 3711(e);
(9) To Federal, State, Tribal, and local regulatory agencies and their employees and contractors who collaborate with Wildlife Services in
implementation of, or agencies that regulate, wildlife management projects or programs, or who have an interest in, or regulate, animal or public health,
or national security;
(10) To Federal or State Government-level representatives of the U.S. Environmental Protection Agency, in compliance with the Federal Insecticide,

Fungicide, and Rodenticide Act (FIFRA) mandate in 7 U.S.C. 136(f, and i thru l), of the location on a cooperator’s property where certain regulated
pesticide devices are deployed or regulated pesticides are applied; and
(11) To the National Archives and Records Administration (NARA) or to the General Services Administration for records management inspections

conducted under 44 U.S.C. 2904 and 2906.
EFFECTS OF FAILURE TO FURNISH INFORMATION
Failure to provide the solicited information will not subject you to penalties or adverse consequences.