Form 0920-22BY Dog Permit Application Form

APPLICATION FOR SPECIAL EXEMPTION FOR A PERMITTED DOG IMPORT

Guidance for completing this application is available at: www.cdc.gov/importation/forms.html.

* Denotes a Required field

FORM APPROVED OMB

NO. 0920-XXXX EXP DATE XX/XX/XXXX

To Submit Electronically via Email Attachment

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• Complete application then save to device

• Email attachment to: [email protected]

SECTION A - APPLICANT
* Last Name:			*First Name:			Middle Initial:
*Intended final destination address (Must be a U.S. Address; no P.O. Boxes):				*City:
* State:	*Zip Code (5 digits only):	*Phone:			*E-mail:
Passport: Passport #: Country:

SECTION B - PERMIT HOLDER (if different from above)
Last Name:			First Name:		Middle Initial:
Mailing Address (Must be a U.S. Address; no P.O. Boxes):			City:
State:	Zip Code(5 digits only):	Phone:		E-mail:
Passport: Passport #: Country:

SECTION C - IDENTIFICATION OF DOG
*Animal Name:				*Country of origin:
*Date of Birth (mm/dd/yy)	*Sex:		*Breed:			*Color:
			If other, specify:
* Microchip #:		* Date of rabies vaccination (mm/dd/yy) - (attach copy)			* 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-XXXX

CS325260 XX/XX/XXXX

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

Section F – Request Details

* Purpose for which the dog is imported:

Personal pet dog Service dog Government-owned Research Rescue, adoption, resale, or transfer of ownership
(including emotional animal
support animals)

* The reason why permission to import is being requested

• Unable to vaccinate against rabies because of research protocols (attached protocols and other supporting documents)

• Other

• High-risk Country (See Section H)

SECTION E - TRAVEL INTINERARY (Complete only one subsection below)

*Air

Airline: *Transport Entry Method (choose one below)

If other, specify: ^{Hand carry}

_{Flight #:} Checked baggage AWB #: ^Cargo

*Land border crossing Private vehicle license plate #: Bus Company: State:

Train Company: ^Province:

*Sea

Ship company/Vessel name: If other, specify:

SECTION G - SUPPORTING DOCUMENTS (Please include the following supporting documents with your application)
	* Serology results (if dog was vaccinated outside the U.S.)
* Rabies Vaccination Certificate	* Photos of dog’s teeth (front and side)

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