VS 17-6 Export Health Certificate for Poultry or Hatching Eggs f

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 0579-0020 and 0579-0328. The time required to complete this
information collection is estimated to average .5 to 2 hours 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.

OMB Approved
0579-0020 and 0328

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 required are provided.
UNITED STATES DEPARTMENT OF AGRICULTURE
1. DATE OF SHIPMENT
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

No.

CERTIFICATE FOR POULTRY OR HATCHING EGGS FOR EXPORT
2. NAME AND ADDRESS OF EXPORTER (include ZIP Code)

3. NAME AND ADDRESS OF IMPORTER

FIPS COUNTRY CODE (for USDA use only)

10. NPIP CLASSIFICATION-U.S.
("X" or check)

Other

Meat-Type

Eggs-Type

Primary
Breeding
Stock

Other

Meat-Type

Multiplier
Breeding
Stock
Eggs-Type

Other

Meat-Type

Eggs-Type

Males

9. NPIP APPROVAL NUMBER

8.TYPE (intended use) ("X" or check)
Commercial
Production
Stock

Females

Straight-run

7. SEX
("X" or check)

Other

Poults

Chicks

5.VARIETY, STRAIN, OR
TRADE NAME

Turkey Eggs

4.QUANTITY/UNIT
(Eggs-Dozen)
(Poultry-Number)

Chicken Eggs

6. PRODUCT
("X" or check)

PullorumTyphoid
Clean`
M.
Gallisepticum
Clean
M.
Meleagridis
Clean
Sanitation
Monitored

FIPS STATE CODE (for USDA use only)

Other
(specify)

11. TOTAL NUMBER OF UNITS CERTIFIED FOR EXPORT
12. CHECK APPROPRIATE CERTIFICATION BELOW (A OR B)
A. Certificate for Hatching Eggs and Newly Hatched Poultry, which have not been fed or watered. This is to certify that: (1) the flock or flocks and the hatchery or
hatcheries from which the above-described hatching eggs or newly hatched poultry originated were inspected by me or another accredited veterinarian within 30
days prior to shipment of above hatching eggs or setting of eggs for above shipment of day old chicks and found free from evidence of communicable diseases
and insofar as can be determined have not been exposed to Newcastle disease, fowl plague, fowl typhoid, ornithosis, and pullorum disease; (2) during the usual
routine inspection of the flock or flocks there was no visible evidence of communicable diseases observed on the inspection dates listed in item 13 below; (3) the
National Poultry Improvement Plan classification is as indicated in item 9 above, and (4) the prospective exporter has been advised that the hatching eggs must
be clean and that the shipment must be made in new, clean containers.
B. Certificate for Poultry other than Newly Hatched Poultry Specified in Certificate A. This is to certify that: (1) on this date all poultry shown in item 5 above,
including all other poultry maintained in the flock, were inspected by me on the premises of origin within the past 30 days and found free from evidence of
infectious and contagious diseases and insofar as can be determined have not been exposed to Newcastle disease, fowl plague, fowl typhoid, ornithosis and
pullorum disease; and (2) the prospective exporter has been advised that shipment must be made in new containers or clean containers which have been
properly cleaned and disinfected.
13. REMARKS OR ADDITIONAL INFORMATION (if needed)

14. TYPED NAME OF ISSUING VETERINARIAN

15. SIGNATURE OF ISSUING VETERINARIAN

16. STATUS

17. DATE ISSUED
1. State

2. Federal

3. Accredited

18. SIGNATURE OF ENDORSING FEDERAL VETERINARIAN (if required)

Clear FormCLEAR FORM

DA

YR

19. DATE ENDORSED
MO

USDA VETERINARY SEAL (if required)

VS FORM 17-6
JUL 2014

MO

DA

YR

VS FORM 17-6 (REVERSE)

CODES
FIPS STATE CODES
01 – Alabama

18 – Indiana

31 – Nebraska

02 – Alaska

19 – Iowa

32 – Nevada

44 – Rhode Island
45 – South Carolina

04 – Arizona

20 – Kansas

33 – New Hampshire

46 – South Dakota

05 – Arkansas

21 – Kentucky

34 – New Jersey

47 – Tennessee

06 – California

22 – Louisiana

35 – New Mexico

48 – Texas

08 – Colorado

23 – Maine

36 – New York

49 – Utah

09 – Connecticut

24 – Maryland

37 – North Carolina

50 – Vermont
51 – Virginia

10 – Delaware

25 – Massachusetts

38 – North Dakota

11 – District of Columbia

26 – Michigan

39 – Ohio

52 – Virgin Island

12 – Florida

27 – Minnesota

40 – Oklahoma

53 – Washington

13 – Georgia

28 – Mississippi

41 – Oregon

54 – West Virginia

15 – Hawaii

29 – Missouri

42 – Pennsylvania

55 – Wisconsin

16 – Idaho

30 – Montana

43 – Puerto Rico

56 – Wyoming

17 – Illinois