0920-0134 Application for Special Exemption for a Permitted Dog Im

APPLICATION FOR SPECIAL EXEMPTION FOR A
PERMITTED DOG IMPORT

FORM APPROVED
OMB NO. 0920-0134
EXP DATE 03/31/2022

Guidance for completing this application is available at: www.cdc.gov/importation/forms.html.
* Denotes a Required field
To Submit Electronically via Email Attachment
• This application is optimized for a desktop/laptop experience
• If not using Adobe Acrobat®, download Acrobat Reader for free
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• Complete application then save to device
• Email attachment to: [email protected]

SECTION A - APPLICANT
1. * Last Name: 2. *First Name:

3. Middle Initial:

4. *Intended final destination address (Must be a U.S. Address; no P.O. Boxes): 5. *City:

6.* State: 7. *Zip Code (5 digits only): 8. *Phone: 9. *E-mail:
American
Alaska
Alabama
District
Delaware
Connecticut
Colorado
California
Arkansas
Arizona
Nevada
Nebraska
Montana
Missouri
Mississippi
Minnesota
Michigan
Massachusetts
Maryland
Maine
Louisiana
Kentucky
Kansas
Iowa
Indiana
Illinois
Idaho
Hawaii
Guam
Georgia
Florida
New
North
Northern
Puerto
Pennsylvania
Oregon
Oklahoma
Ohio
Rhode
South
U.S.
Virginia
Vermont
Utah
Texas
Tennessee
West
Washington
Wyoming
Wisconsin
Virgin
Hampshire
Jersey
Mexico
York
Virginia
Carolina
Dakota
Carolina
Dakota
Rico
Island
ofMariana
Columbia
Samoa
IslandsIslands

10. Passport:

11. USCIS or US Visa # (*Required if applicable):

Passport #:

USCIS #:

Country:

Visa#:

Antigua
Angola
Andorra
Algeria
Albania
Afghanistan
Azerbaijan
Austria
Australia
Armenia
Argentina
Bosnia
Bolivia
Bhutan
Benin
Belize
Belgium
Belarus
Barbados
Bangladesh
Bahrain
Burkina
Bulgaria
Brunei
Brazil
Botswana
Cape
Canada
Cameroon
Cambodia
Burundi
Central
Comoros
Colombia
China
Chile
Chad
Congo,
Costa
Cote
Czech
Cyprus
Cuba
Croatia
Dominican
Dominica
Djibouti
Denmark
East
El
Egypt
Ecuador
Equatorial
The
Gabon
France
Finland
Fiji
Ethiopia
Estonia
Eritrea
Kiribati
Kenya
Kazakhstan
Jordan
Japan
Jamaica
Italy
Israel
Ireland
Iraq
Iran
Indonesia
India
Iceland
Hungary
Honduras
Haiti
Guyana
Guinea-Bissau
Guinea
Guatemala
Grenada
Greece
Ghana
Germany
Georgia
Korea,
Marshall
Malta
Mali
Maldives
Malaysia
Malawi
Madagascar
Macedonia
Luxembourg
Lithuania
Liechtenstein
Libya
Liberia
Lesotho
Lebanon
Latvia
Laos
Kyrgyzstan
Kuwait
Kosovo
Micronesia,
Mexico
Mauritius
Mauritania
Myanmar
Mozambique
Morocco
Montenegro
Mongolia
Monaco
Moldova
New
Netherlands
Nepal
Nauru
Namibia
Papua
Panama
Palau
Pakistan
Oman
Norway
Nigeria
Niger
Nicaragua
Rwanda
Russia
Romania
Qatar
Portugal
Poland
Philippines
Peru
Paraguay
Saint
San
Samoa
Sao
Saudi
Sierra
Seychelles
Serbia
Senegal
Solomon
Slovenia
Slovakia
Singapore
Somalia
South
Sri
Spain
Trinidad
Tonga
Togo
Thailand
Tanzania
Tajikistan
Taiwan
Syria
Switzerland
Sweden
Swaziland
Suriname
Sudan
Ukraine
Uganda
Tuvalu
Turkmenistan
Turkey
Tunisia
United
Vatican
Vanuatu
Uzbekistan
Uruguay
Zimbabwe
Zambia
Yemen
Vietnam
Venezuela
Salvador
Lanka
Bahamas
Gambia
Marino
Tome
Zealand
Timor
d’Ivoire
Kitts
Lucia
Vincent
Verde
Arabia
Rica
Africa
Sudan
Leone
Republic
Arab
Kingdom
States
New
North
South
and
African
Republic
Democratic
City
Faso
and
and
Islands
Islands
(Burma)
Guinea
and
and
Republic
(Timor-Leste)
Herzegovina
Federated
Guinea
Emirates
(Holy
Barbuda
Tobago
and
ofNevis
Principe
Republic
America
ofthe
See)
the
Republic
Grenadines
Statesofofthe

SECTION B - PERMIT HOLDER (if different from above)
12. Last Name:

13. First Name:

15. Mailing Address (Must be a U.S. Address; no P.O. Boxes):

17. State:

18. Zip Code(5 digits only):

14. Middle Initial:

16. City:

19. Phone:

American
Alaska
Alabama
District
Delaware
Connecticut
Colorado
California
Arkansas
Arizona
Nevada
Nebraska
Montana
Missouri
Mississippi
Minnesota
Michigan
Massachusetts
Maryland
Maine
Louisiana
Kentucky
Kansas
Iowa
Indiana
Illinois
Idaho
Hawaii
Guam
Georgia
Florida
New
North
Northern
Puerto
Pennsylvania
Oregon
Oklahoma
Ohio
Rhode
South
U.S.
Virginia
Vermont
Utah
Texas
Tennessee
West
Washington
Wyoming
Wisconsin
Virgin
Hampshire
Jersey
Mexico
York
Virginia
Carolina
Dakota
Carolina
Dakota
Rico
Island
ofMariana
Columbia
Samoa
IslandsIslands

21. Passport:

20. E-mail:

22. USCIS or US Visa # (*Required if applicable):

Passport #:

USCIS #:

Country:

Visa#:

Antigua
Angola
Andorra
Algeria
Albania
Afghanistan
Azerbaijan
Austria
Australia
Armenia
Argentina
Bosnia
Bolivia
Bhutan
Benin
Belize
Belgium
Belarus
Barbados
Bangladesh
Bahrain
Burkina
Bulgaria
Brunei
Brazil
Botswana
Cape
Canada
Cameroon
Cambodia
Burundi
Central
Comoros
Colombia
China
Chile
Chad
Congo,
Costa
Cote
Czech
Cyprus
Cuba
Croatia
Dominican
Dominica
Djibouti
Denmark
East
El
Egypt
Ecuador
Equatorial
The
Gabon
France
Finland
Fiji
Ethiopia
Estonia
Eritrea
Kiribati
Kenya
Kazakhstan
Jordan
Japan
Jamaica
Italy
Israel
Ireland
Iraq
Iran
Indonesia
India
Iceland
Hungary
Honduras
Haiti
Guyana
Guinea-Bissau
Guinea
Guatemala
Grenada
Greece
Ghana
Germany
Georgia
Korea,
Marshall
Malta
Mali
Maldives
Malaysia
Malawi
Madagascar
Macedonia
Luxembourg
Lithuania
Liechtenstein
Libya
Liberia
Lesotho
Lebanon
Latvia
Laos
Kyrgyzstan
Kuwait
Kosovo
Micronesia,
Mexico
Mauritius
Mauritania
Myanmar
Mozambique
Morocco
Montenegro
Mongolia
Monaco
Moldova
New
Netherlands
Nepal
Nauru
Namibia
Papua
Panama
Palau
Pakistan
Oman
Norway
Nigeria
Niger
Nicaragua
Rwanda
Russia
Romania
Qatar
Portugal
Poland
Philippines
Peru
Paraguay
Saint
San
Samoa
Sao
Saudi
Sierra
Seychelles
Serbia
Senegal
Solomon
Slovenia
Slovakia
Singapore
Somalia
South
Sri
Spain
Trinidad
Tonga
Togo
Thailand
Tanzania
Tajikistan
Taiwan
Syria
Switzerland
Sweden
Swaziland
Suriname
Sudan
Ukraine
Uganda
Tuvalu
Turkmenistan
Turkey
Tunisia
United
Vatican
Vanuatu
Uzbekistan
Uruguay
Zimbabwe
Zambia
Yemen
Vietnam
Venezuela
Salvador
Lanka
Bahamas
Gambia
Marino
Tome
Zealand
Timor
d’Ivoire
Kitts
Lucia
Vincent
Verde
Arabia
Rica
Africa
Sudan
Leone
Republic
Arab
Kingdom
States
New
North
South
and
African
Republic
Democratic
City
Faso
and
and
Islands
Islands
(Burma)
Guinea
and
and
Republic
(Timor-Leste)
Herzegovina
Federated
Guinea
Emirates
(Holy
Barbuda
Tobago
and
ofNevis
Principe
Republic
America
ofthe
See)
the
Republic
Grenadines
Statesofofthe

SECTION C - IDENTIFICATION OF DOG
23. *Country of Origin: 24. *Length of time (in months) in country of origin:
Antigua
Angola
Andorra
Algeria
Albania
Afghanistan
Azerbaijan
Austria
Australia
Armenia
Argentina
Bosnia
Bolivia
Bhutan
Benin
Belize
Belgium
Belarus
Barbados
Bangladesh
Bahrain
Burkina
Bulgaria
Brunei
Brazil
Botswana
Cape
Canada
Cameroon
Cambodia
Burundi
Central
Comoros
Colombia
China
Chile
Chad
Congo,
Costa
Cote
Czech
Cyprus
Cuba
Croatia
Dominican
Dominica
Djibouti
Denmark
East
El
Egypt
Ecuador
Equatorial
The
Gabon
France
Finland
Fiji
Ethiopia
Estonia
Eritrea
Kiribati
Kenya
Kazakhstan
Jordan
Japan
Jamaica
Italy
Israel
Ireland
Iraq
Iran
Indonesia
India
Iceland
Hungary
Honduras
Haiti
Guyana
Guinea-Bissau
Guinea
Guatemala
Grenada
Greece
Ghana
Germany
Georgia
Korea,
Marshall
Malta
Mali
Maldives
Malaysia
Malawi
Madagascar
Macedonia
Luxembourg
Lithuania
Liechtenstein
Libya
Liberia
Lesotho
Lebanon
Latvia
Laos
Kyrgyzstan
Kuwait
Kosovo
Micronesia,
Mexico
Mauritius
Mauritania
Myanmar
Mozambique
Morocco
Montenegro
Mongolia
Monaco
Moldova
New
Netherlands
Nepal
Nauru
Namibia
Papua
Panama
Palau
Pakistan
Oman
Norway
Nigeria
Niger
Nicaragua
Rwanda
Russia
Romania
Qatar
Portugal
Poland
Philippines
Peru
Paraguay
Saint
San
Samoa
Sao
Saudi
Sierra
Seychelles
Serbia
Senegal
Solomon
Slovenia
Slovakia
Singapore
Somalia
South
Sri
Spain
Trinidad
Tonga
Togo
Thailand
Tanzania
Tajikistan
Taiwan
Syria
Switzerland
Sweden
Swaziland
Suriname
Sudan
Ukraine
Uganda
Tuvalu
Turkmenistan
Turkey
Tunisia
United
Vatican
Vanuatu
Uzbekistan
Uruguay
Zimbabwe
Zambia
Yemen
Vietnam
Venezuela
Salvador
Lanka
Bahamas
Gambia
Marino
Tome
Zealand
Timor
d’Ivoire
Kitts
Lucia
Vincent
Verde
Arabia
Rica
Africa
Sudan
Leone
Republic
Arab
Kingdom
New
North
South
and
African
Republic
Democratic
City
Faso
and
and
Islands
Islands
(Burma)
Guinea
and
and
Republic
(Timor-Leste)
Herzegovina
Federated
Guinea
Emirates
(Holy
Barbuda
Tobago
and
Nevis
Principe
Republic
ofthe
See)
the
Republic
Grenadines
Statesofofthe

25. *Date of Birth

26. *Sex:

27. *Breed:

28. *Color:

(mm/dd/yy)

Other/Mixed
Afghan
Akita
Australian
Basset
Besenji
Barbet
Beauceron
Beagle
Belgian
Bernese
Bernedoodle
Bichon
Bouvier
Borzoi
Boerboel
Bloodhound
Bracco
Boxer
Briquet
Briard
Brussels
Brittany
Bulldog,
Bully,
Bullmastiff
Chinese
Chihuahua
Chow
Collie,
Coonhound,
Corgi
Corgi,
Coton
Czechoslovakian
Dane,
Dalmatian
Dachshund
Deutsch
Doberman
Dogue
Elkhound
Entlebucher
Entelbucher
Eskimo
Eurasier
Foxhund,
Foxhound,
Greyhound,
Greyhound
Goldendoodle
Husky
Havanese
Husky,
Kai
Jindo
Labradoodle,
Koolie
Komondor
Keeshond
Lagotto
Lhasa
Leonberger
Malamute,
Maltese
Mastiff,
Mountain,
Petit
Pekingese
Peke-A-Poo
Papillon
Pinscher,
Pointer,
Pomeranian
Poodle,
Portuguese
Pyrenees,
Puli
Puggle
Pug
Pudelpointer
Retriever,
Rhodesian
Saint
Rottweiler
Schipperke
Samoyed
Saluki
Schnauzer,
Setter,
Shar-Pei,
Shar-Pei
Sheepdog,
Sheepadoodle
Shepherd,
Shiba
Shih
Spaniel,
Spinone
Stabyhoun
Terrier,
Wirehaired
Whippet
Weimaraner
Vizsla
Wolfhound,
Ken
Basset
Tzu
(American)
Inu
Berdoodle
American
Chow
Inu
Welsh
Welsh,
de
Great
Apso
Border
Rough
de
English
Gordon
Irish
Alaskan
Siberian
Hound
Frise
Italiano
Griffon
Hound
Airedale
American
Bedlington
Black
Border
Boston
Bull
Cairn
Cesky
Fox
Fox,
Irish
Jack
Kerry
Manchester
Norfolk
Pit
Rat
Russell
Scottish,
Silky
Soft
Staffordshire
Tibetan
West
Wheaten
Yorkshire,
English
French
Neapolitan
Dog,
Malinois
Sheepdog
Tervuren
Romagnolo
des
Miniature
Standard
Teacup
Toy
English
German
American
Cavalier
Clumber
English
French
Irish
King
Springer
Crested
Drahthaar
Italiano
Mountain
Griffon
(Japanese)
Tulear
German
Miniature
Chinese
Norwegian
Black
Chesapeake
Curly-Coated
Flat-Coated
Golden
Laborador
Nova
Bordeaux
Greater
Cattle
Cobberdog
Great
American
Anatolian
Autralian
Dutch
English
German
Shiloh
Bull
Pinscher
Alaskan
American
English
Ridgeback
Pointing
Polish
Giant
Miniature
Standard
Irish
Red
Water
Miniature
Toy
Italian
Coated
Flandres
Mountain
Sennenhund
Griffon
Smooth
Wire
(specify
American
Black
Russell
American
Highland
Water
Australian
Blue
Charles
Russian
Pembroke
orVendeen
or
and
Scotia
Smooth
Cocker
Springer
Toy
and
Scottie
Longhaired
Shorthaired
Wirehaired
Vlcak
King
Pit
Staffordshire
Toy
Haired
Norwich
Lowland
Yorkie
Swiss
Cocker
Water
Dog
and
Vendeen
Griffon
Wheaten
Tan
White
Bull
below)
Haired
Charles
English
White,
Duck-Tolling
Tan
Bay
(Wolfdog)
or
or
Virginian
American
or
Canadian
American
Old
Westie
English

Female
Male
Intact
Neutered
Intact
Neutered

29. *Microchip #:

If other, specify:

30. Date of rabies vaccination
(mm/dd/yy) - (attach copy)

31. Date

of serology if applicable
(mm/dd/yy)- (attach copy)

Public reporting burden of this collection of information is estimated to average 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. An agency may not conduct
or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports
Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329; ATTN: PRA 0920-0134

RESET FORM
CS325260 7/19/2021

SAVE FORM

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Page 1 of 2

SECTION D - ENTRY AND FINAL DESTINATION
32. *Date of entry for intended importation into
the United States (mm/dd/yy):

33. *U.S. port of entry for intended importation
WY,
WA,
WI,
WV,
Appleton
Ashland
Green
Manitowoc
Marinette
Milwaukee/General
Racine/Batten
Sheboygan
Spokane
Sumas
Tacoma
Vancouver
Yakima
Charleston/Yeager
Casper-Natrona
Bay-Austin
Air
International
Terminal
County
Straubel
Mitchell
Airport
International
(CRW)
International
(ATW)
(RAC)
Airport
Airport
(CPR)
(GRB)
(MKE)
AK,Waukegan
AL,
AR,
AZ,
CA,
CO,
CT,
DC,
DE,
FL,
GA,
GU,
HI,
IA,
ID,
IL,
IN,
KS,
KY,
LA,
MA,
MD,
ME,
MI,
MN,
MO,
MP,
MS,
MT,
NC,
ND,
NE,
NH,
NJ,
NM,
NV,
NY,
OH,
OK,
OR,
PA,
PR,
RI,
SC,
SD,
TN,
TX,
UT,
VA,
VI,
VT,
Chicago
Chicago/O'Hare
Decatur
DuPage
General
MidAmerica
Midway
Moline/Quad
Des
Charlotte
Cruz
Frederiksted
St
Hilo
Honolulu
Kahului
Kona
Nawiliwili-Port
Boise
Eastport
Porthill
East
Fort
Gary
Indianapolis
Mellville
Newport
Providence/TF
Algonac
Alpena
Battle
Detour
Detroit
Detroit/Ambassador
Escanaba
Ferrysburg
Grand
Lansing/Capital
Mackinac
Marquette
MBS
Muskegon
Oakland
Port
Rogers
Sault
South
Willow
Apalachicola
Cape
Daytona
Fernandina
Fort
Jacksonville
Key
Leesburg
Miami
Naples
Ocala
Orlando
Orlando/Melbourne
Orlando/Sanford
Palm
Panama
Pensacola
Sarasota-Bradenton
St
Tampa
Atlantic
Morristown
Newark
Perth
Trenton/Mercer
Birmingham-Shuttlesworth
Huntsville
Mobile
Baton
Gramercy
Lake
Louis
Morgan
Shreveport
Douglas/Raul
Lukeville
Naco
Nogales
Nogales/Deconcini
Phoenix
Sasabe
Scottsdale
Tucson
Addison
Austin-Bergstrom
Beaumont
Brownsville
Corpus
Dallas
Dallas/Ft
Del
Eagle
El
Fort
Freeport
Hidalgo/Pharr
Houston
Houston/George
Laredo-Lincoln/Juarez
Lubbock
McKinney
Midland
Orange
Port
Presidio
Progreso
Rick
Rio
Roma
Sabine
San
Sugar
Tornillo/Fort
Beecher
Burlington
Derby
Highgate
Norton
Richford
St
Bridgeport
Hartford/Bradley
New
Chattanooga
Knoxville
Memphis
Nashville
Tri-Cities
Salt
Alcan
Dalton
Fairbanks
Juneau
Ketchikan
Kodiak
Pelican
Petersburg
Sitka
Skagway
Ted
Valdez
Wrangell
Wichita/Dwight
Cincinnati/Northern
Lexington/Bluegrass
Louisville
Owensboro
Chester
Erie
Harrisburg
Philadelphia
Pittsburgh
Dulles
Norfolk
Richmond
Little
Rogers
Andrade
Calexico
Eureka
Fresno
Los
Meadows
Mineta
Monterey
Oakland
Otay
Palm
Port
Sacrament
Tecate
Victorville/Southern
Wilmington
Eppley
Las
Reno-Tahoe
Albany
Alexandria
Binghamton
Buffalo
Buffalo/Niagara
Champlain
Clayton
Greater
John
LaGuardia
Massena
Ogdensburg
Oswego
Rochester
Rome/Griffiss
Sodus
Syracuse
Trout
Utica
Aguadilla/Rafael
Fajardo
Guanica
Guayanilla
Humacao
Jobos
Mayaguez
Ponce
Rafael
San
Charleston
Columbia
Georgetown
Greenville-Spartanburg
Myrtle
Rapid
Sioux
Reagan
Bert
Bozeman
Del
Glacier
Great
Morgan
Opheim
Piegan
Raymond
Roosville
Scobey
Sweetgrass
Turner
Whitetail
Whitlash
Wild
Willow
Charlotte-Douglas
Greensboro/Winston-Salem/Piedmont
Morehead
Raleigh
Ambrose
Antler
Carbury
Dunseith
Fargo/Hector
Fortuna
Grand
Hannah
Hansboro
Maida
Minot
Neche
Noonan
Northgate
Pembina
Portal
Saint
Sarles
Sherwood
Walhalla
Westhope
Williston/Sloulin
Manchester-Boston
Portsmouth
Brunswick
Hartsfield-Jackson
Savannah/Hilton
Oklahoma
Tulsa
Centennial
Denver
Eagle
Rocky
Hagatna/Antonio
Boston
Boston/Logan
Fall
Gloucester
Lawrence
New
Plymouth
Provincetown
Salem
Springfield
Worcester
Bangor
Belfast
Bridgewater
Calais/Milltown
Eastport
Fort
Houlton
Jackman/Coburn
Jonesport
Lebanon
Limestone
Madawaska
Rockland
Searsport
Van
Vanceboro
Rota
Saipan
Tinian
Greenville
Gulfport-Biloxi
Jackson-Medgar
Pascagoula
Ashtabula/Conneaut
Cleveland
Columbus/Rickenbacker
Dayton
Erie-Ottawa
Astoria
Coos
Newport
Portland
Portland-Hillsboro
Baltimore/Washington
Baudette
Crane
Duluth
Grand
International
Lancaster
Minneapolis-St
Noyes
Pinecreek
Rochester
Roseau
Silver
Warroad
Winnipeg
Albuquerque
Columbus
Santa
Kansas
Lambert-St
Spirit
Springfield-Branson
Aberdeen
Anacortes
Bellingham
Blaine
Boundary
Danville
Everest
Ferry
Friday
Frontier
Grant
Kalama
Laurier
Longview
Lynden
Metaline
Neah
Nighthawk
Olympia
Oroville
Point
Port
Seattle-Tacoma
Croix
Croix/Henry
Augustine/Northeast
Pete-Clearwater
Paso/El
Albans
International
Moines
Wayne
Rio/Del
Grande
West
Bonita
Lauderdale-Hollywood
Myers/Southwest
Pierce
Huron
Angeles
Angeles/Long
Manatee
St.
Chicago
Vegas/McCarran
Worth
Lake
Bay/St
Stevens
Luis
Antonio
River
International
Arthur-Beaumont
Lavaca-Point
Bernardino
Diego
Francisco
Ysidro
Juan
Juan/Luis
Husband
Hueneme
Fairfield
Kent
International
Mooney
Buren
Haven
London
River
Horse
Sainte
Charles/Chennault
Beach
Angeles
Townsend
Bedford
Rock/Clinton
Mesa
Airport
Canaveral
F
International
Amboy
Armstrong
Springs
Creek/WK
John
River
Haven
Regional
International
Seaport
Bay
Pass
Rouge
of
Haven
Rapids/Gerald
Falls
Roberts
Line
Land
Run
City
Bay
Metropolitan
Love
County
Beach
International
Teresa
International
Forks
Cache/Haines
Point
Mountain
Lake
Municipal
Hernandez
Creek
City
Portage
Airport
Aiport
Harbor
San
Wayne
International
Airfield
Kennedy
Airport
Yosemite
City
Christi
Joe
Executive
Rockford
Niagara
International
Park
Liberty
Municipal
City
Seaport
International
Executive
Rochester
International
Durham
County
City
Sky
Beach
Airport
National
Harbor
International
St
Seaport
Amalie
Amalie/St
Falls/Canaan
Preston
East
West
Worth
Springs
Regional
Isle
International
Falls
Airport
International
City
Hancock
International
Metropolitan
National
Seaport
Field
Yellowstone
International
International
Paso
Valley
City
International
Hopkins
Airport
Regional
Alliance
City/Will
International
Airport
St
Bay
Regional
International
Louis
Beach
Regional
Airport
John
International
Rio
City
Jose
Regional
Airport
Field
City
Marie
Louis
International
Hancock
(BOI)
International
Harbor
International
Ontario
Anchorage
-Falls
Metropolitan
Airport
Allen
International
(DEC)
Hector
International
Louis
International
E
Green
Amarillo
Regional
(OGG)
Airport
Airport,
Mark
International
(DPA)
Munoz
International
Seaport
Omaha
A
International
D
Airport
Region
International
County
International
Airport
(ADS)
Paul
International
Falls/Lewiston
Rohlsen
Field
International
Kellogg
Airport
New
International
Bush
Metropolitan
Hernandez
Downing
Airport
International
Head
Smith
Wiley
Airport
Eisenhower
Airport,
International
B
Gore
Airport
(SCF)
International
Comfort
(MMU)
Airport
Beach
Airport
National
International
(APA)
Airport
Thomas/Cyril
International
Atlanta
Airport
International
Airport
International
Rogers
Kentucky
Airport
Won
Bridge
California
Airport
Andrews
Regional
International
Airport
(BTM)
Airport
National
International
Airport
Castro
R
Airport
Air
Airport
Orleans
International
Hwy
International
Florida
Jetport
Marin
Moses
Airport
Bridge
Station/Pittsburg
International
Airport
Thurgood
(BFL)
International
Airport
International
Florida
Airport
Ford
Evers
International
Airport
(ITO)
International
Airport
Airport
Airport
International
(APF)
and
International
(DCA)
(SUS)
Airport
(ERI)
Pat
(MBS)
(ROG)
International
Airport
(PWK)
(KOA)
Dublin
Seaport
Airport
(ORL)
(ROP)
(HIO)
Airport
(TRI)
(UGN)
(MIA)
(TKI)
Airport
(MOT)
Peoria
(TUL)
International
(AFW)
Airport
Sunport
(DTW)
International
Airport
(IAD)
International
(BLV)
Airport
(TPA)
World
Airport
(RAP)
(DLH)
(ALB)
(ORF)
Airport
(SHV)
(TUS)
(LEX)
(SPN)
(JNU)
Airport
(ONT)
(DAY)
-(DEN)
(BGR)
(MCO)
(PVD)
International
Airport
International
Airport
(SGR)
(HNL)
Space
International
Airport
International
(PDX)
Airport
Lake
Joe
Airport
(LEE)
(PWM)
(MEM)
(BNA)
International
National
Airport
(EYW)
(SDF)
Logistics
International
(OMA)
(HSV)
Airport
(BDE)
(CAE)
(FAI)
Airport
(KTN)
Regional
(BTV)
(RIC)
(PNS)
(PIT)
Bridge/Peace
(EGE)
Airport
(SBD)
(RST)
(FWA)
(DSM)
(SMF)
Airport
(GTF)
(IND)
(ILM)
Airport
Airport
(STX)
(JAX)
(PSM)
(PBI)
Airport
E
(SAT)
(PCW)
(PHL)
Marshall
(LAX)
Airport
(FCA)
(MCI)
(RNO)
International
(CHA)
Foss
(MYR)
Airport
(FAR)
(PSP)
(RME)
(SLC)
Airport
(LIT)
(CRP)
Airport
King
(BOS)
(GPT)
(SFO)
(ABQ)
(EWR)
(ORD)
Airport
(DAB)
(BQN)
(DRT)
Airport
Port
(DFW)
Airport
(SBD)
Airport
(ELP)
(MLI)
Airport
(SFB)
(MHT)
(SGF)
(BDL)
(BJC)
(RDU)
(SEA)
(JFK)
Airport
(RFD)
(SJC)
Airport
(FAT)
(AUS)
Airport
(STL)
Triad
Airport
(CLT)
(ROC)
(PIE)
Airport
Field
(SYR)
(MLB)
Station
(CLE)
Airport
Airport
(SRQ)
(PHX)
(MAF)
(MSP)
(OKC)
Airport
Airport
(LAS)
Airport
(ISN)
International
Airport
(IAH)
Airport
Airport
(BZN)
(AMA)
(LAN)
(SAV)
(LBB)
(GSP)
International
(CWF)
(ANC)
(FSD)
(BTL)
Bridge/Rainbow
(LCK)
(ICT)
Airport
(VCV)
(BMH)
(ATL)
(STT)
(FLL)
(UST)
(SJU)
(GRR)
(GUM)
(RSW)
(GFK)
(CVG)
(JAN)
(MSY)
(PIA)
Airport
Airport
Bridge/Whirlpool
(BWI)
(GSO)
Bridge

SECTION E - TRAVEL INTINERARY (Complete only one subsection below)
34. *Air
Airline:

*Transport Entry Method (choose one below)

Other/Charter
Aer
Aeroflot
Aeroméxico
Air
Alaska
All
Alitalia
American
Asiana
British
Avianca
Cathay
China
Delta
Ethiopian
Emirates
Etihad
EVA
Hawaiian
Japan
Jet
JetBlue
KLM
Korean
Lufthansa
Malaysia
Luxair
Pakistan
Philippine
Qantas
Qatar
Royal
SAS
Singapore
South
Southwest
Swiss
Thai
Turkish
United
Virgin
Nippon
Canada
China
France
India
New
Airlines
Lingus
Airways
Airlines
(Scandanavian
(Royal
Air
Airways
Air
Jordanian
Atlantic
International
Airlines
Eastern
Southern
African
Airlines
Airways
Airlines
Airlines
Pacific
Air
Airways
Airlines
Airways
Russian
Zealand
Lines
International
Airlines
Maroc
Airlines
Airlines
Airlines
(Deutsche
Airways
Airlines
Airlines
Limited
Dutch
International
Airways
(specify
Airlines
Airways
Airlines
Airlines
Airlines
Airlines)
Air
Airlines)
Lufthansa
Airlines
below)
Lines
AG)

Hand carry

If other, specify:

Checked baggage

Flight #:

Cargo

AWB #:
35. *Land border crossing

Private vehicle license plate #:

Bus Company:

State:

Train Company:

Province:

American
Alaska
Alabama
District
Delaware
Connecticut
Colorado
California
Arkansas
Arizona
Nevada
Nebraska
Montana
Missouri
Mississippi
Minnesota
Michigan
Massachusetts
Maryland
Maine
Louisiana
Kentucky
Kansas
Iowa
Indiana
Illinois
Idaho
Hawaii
Guam
Georgia
Florida
New
North
Northern
Puerto
Pennsylvania
Oregon
Oklahoma
Ohio
Rhode
South
U.S.
Virginia
Vermont
Utah
Texas
Tennessee
West
Washington
Wyoming
Wisconsin
Virgin
Hampshire
Jersey
Mexico
York
Virginia
Carolina
Dakota
Carolina
Dakota
Rico
Island
ofMariana
Columbia
Samoa
IslandsIslands

BritishBrunswick
Alberta
New
Manitoba
Newfoundland
Nova
Prince
Ontario
Saskatchewan
Quebec
Scotia
Columbia
Edward and
Island
Labrador

36. *Sea
Ship company/Vessel name:

AIDA
AmaWaterways
American
Avalon
Azamara
Bahamas
Bimin
Carnival
Celebrity
Costa
Crystal
Cunard
Disney
Fred
Great
Hapag-Lloyd
Holland
Hurtigruten
M/T
Majestic
MS
MSC
Norwegian
NYK
Oceania
Other
P&O
Paul
Pearl
Ponant
Princess
Regent
Resorts
Royal
Sea
Seabourn
Silversea
Uniworld
V.
Venus
Viking
Virgin
Voyages
Windstar
Ships
-Eagle
Dream
Gauguin
Olsen
Cruises
A'Sara
Esplanade
Queen
Cruises
Cruises
Seas
-Lakes
Caribbean
Cruise
Cruises
Cruises
Cruise
Cruise
Waterways
Superfast
Cruises
Bow
Damgarcht
Falcon
Kwai
MSC
Ocean
Other
Overseas
Sanko
-Seven
Line
America
World
Cruise
Cruises
Leisure
Le
Cruises
Boutique
of
Cruises
Club
Cruises
Cruise
Paradise
Cruise
Saporro
Cruise
Cruises
-Cruise
Discovery
Yacht
Boreal
Leopard
Hansa
-Vesteralen
Cruise
Finnmarken
Fram
Kong
Lofoten
Midnatsol
MS
Nordkapp
Nordlys
Nordnorge
Nordstjernen
Polarlys
Richard
Trollfjord
Debra
Cruises
Co.,
Ships
---Queen
Cruises
Lines
Ability
-Cruises
Crystal
Seas
Adonia
Arcadia
Aurora
Azura
Britannia
Oriana
-Ventura
Trader
Armonia
Divina
Fantasia
Lirica
Magnifica
Melody
Meraviglia
Musica
Opera
Orchestra
Poesia
Rhapsody
Seaside
Silvana
Sinfonia
Splendida
Luna
Vita
Pacific
,Lines
Lines,
Allegra
Atlantica
Classica
Deliziosa
Europa
Favolosa
Fortuna
Luminosa
Magica
Marina
Mediterranea
Pacifica
Romantica
Serena
Victoria
Bimini
-Viking
U.S.A.
Inc.
Line
Expedition
Lines
-International
-Line
Amacello
Amadagio
Amadante
Amadolce
Amadouro
Amalegro
Amalyra
La
Swiss
-Tolstoy
Yosemite
Ltd
LTD
Club
Lines
Insignia
Nautica
Oceania
Regatta
Riviera
Sirena
Caribbean
Coral
Crown
Dawn
Diamond
Emerald
Golden
Grand
Island
Majestic
Ocean
Pacific
Regal
Royal
Ruby
Sapphire
Sea
Sky
Star
Sun
Tahitian
Line
River
Harald
Celebrity
Pride
Star
Wind
--Cruise
-Company
Affinity
Artistry
Creativity
Felicity
Imagery
Luminary
Poetry
Scenery
Tapestry
-Tranquility
Marguerite
M/T
Scarlet
Pearl
-With
-Victoria
Elizabeth
Mary
-Disney
Seven
II-Inc.
Crystal
Venus
Superfast
MS
MV
-Princess
Sea
Sky
Sun
Prince
Silver
Freewinds
Amsterdam
Eurodam
Koningsdam
Maasdam
Nieuw
Noordam
Oosterdam
Prinsendam
Rotterdam
Ryndam
Statendam
Veendam
Volendam
Westerdam
Zaandam
Zuiderdam
Princess
-MV
Encore
Legend
Odyssey
Pride
Seabourn
Sojourn
Spirit
Paul
-Pearl
Azamara
Journey
Quest
Asuka
-Star
Eagle
Glory
Independence
Spirit
Princess
Cruise
Spirit
Star
Surf
SeaDream
Balmoral
Princess
Eagle
Princess
Amadea
MV
Princess
Norwegian
Pride
Princess
Princess
Line
-Europa
Bremen
Mist
2Princess
Marina
Princess
Discovery
Carnival
Princess
Century
Constellation
Eclipse
Edge
Equinox
Infinity
Mercury
Millennium
Reflection
Silhouette
Solstice
Summit
Xpedition
Lady
Gauguin
Seas
Cloud
Discoverer
Explorer
Muse
Shadow
Spirit
Whisper
Wind
Dream
Fantasy
Magic
Wonder
Yorktown
Princess
Amsterdam
Statendam
Albert
-Symphony
Serenity
IIMV
-of
Saporro
Adventure
Allure
Anthem
Brilliance
Empress
Enchantment
Explorer
Freedom
Grandeur
Harmony
Independence
Jewel
Legend
Liberty
Majesty
Mariner
Monarch
Navigator
Oasis
Ovation
Quantum
Radiance
Rhapsody
Serenade
Splendour
Symphony
Vision
Voyager
Collection
Grand
Pursuit
Quest
America
Explorer
Mariner
Navigator
Splendor
Voyager
2Victory
IIIVista
II
Breeze
Conquest
Dream
Ecstasy
Elation
Fantasy
Fascination
Freedom
Glory
Horizon
Imagination
Inspiration
Legend
Liberty
Magic
Miracle
Panorama
Paradise
Pride
Sensation
Spirit
Splendor
Sunrise
Sunshine
Triumph
Valor
Victory
Bliss
Breakaway
Dawn
Encore
Epic
Escape
Gem
Getaway
Jade
Jewel
Joy
Majesty
Pearl
Sky
Star
Sun
of
of
of
Celebration
Classica
of
of
the
of
the
of
of
the
of
of
of
-the
of
the
of
Ithe
the
Douro
River
the
the
Seas
the
the
Seas
the
Seas
the
of
Seas
Seas
of
Seas
Seas
Seas
Seas
the
Seas
Seas
Seas
the
Seas
Ambassador
Baroness
Beatrice
Countess
Duchess
Empress
Princess
Queen
Royale
Tosca
Queen
Seas
Seas

If other, specify:

SECTION F - REQUEST DETAILS
37. *Purpose for which the dog is being imported:
Personal Pet

Service Dog

Government Owned Animal Research Other:

38. *The reason why permission to import is being requested:
Unable to vaccinate against rabies because of research protocols
(attach protocols and other supporting documents)

Other:

High-risk country

SECTION G - SUPPORTING DOCUMENTS

(Please include the following supporting documents with your application)
39.

* Proof of Relocation or Service Dog (Employment
Verification, University Acceptance, Official Orders, etc.)

40.

* Rabies Vaccination Certificate

41.

42.

* Photos of dog’s teeth (front and side)

43.

* Copy of Photo Page of Passport and Visa/USCIS card
(if applicable)

* Serology results (if dog was vaccinated outside the U.S.)

SECTION H - SIGNATURE
I am the owner (or authorized agent for the owner) of the dog listed on this form. I understand that ownership of the dog cannot be transferred to another
person while in confinement. The dog must be confined at the address listed on this form and may not be placed at any other location or with any other
person until the confinement period has ended.
I certify that the information given in this application is complete and true to the best of my knowledge.
I agree to obey the conditions listed in this application. I will comply with all restrictions and precautions in the permit, as well as all applicable
import regulations.
I understand that I may be convicted of a crime if I don’t comply with these import requirements. I could be sentenced to 1 year in jail and/ or a maximum
fineof $100,000 if the violation doesn’t result in a death or a maximum fine of $250,000 if the violation does result in a death. Violations by an organization
arepunishable by a maximum fine of $200,000 per violation (if no death) and $500,000. These penalties are provided for under 42 U.S.C. §264 and 42 U.S.C.
§271 (as enhanced by 18 U.S.C. §§ 3559 & 3571).

*I understand that checking this box constitutes a legal signature confirming that I acknowledge
and agree to the above Terms of Acceptance.
44. *Legal Signature: Typed First, Middle Initial and Last Name:

RESET FORM
CS325260 7/19/2021

45. *Date Signed(mm/dd/yy):

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