NVSL Contact Information Update

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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 0579-0430.  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 maintaining the data needed, and completing and reviewing the collection of information.
OMB Approved
0579-0430
Exp. 02/2025
United States Department of Agriculture
Animal and Plant Health Inspection Service
Veterinary Services
NVSL Contact Information Update
Name of Business/Laboratory (Required):

Business type:

Address 1:

Address 2:

City:

State/Province:

Postal Code:
Country:

Business Phone Number (Required):

Business Fax Number (Optional):
Business Premises ID:

Business Email Address(s) (To be included in all reports associated with this business):

Individuals Authorized to Submit and Incur Expenses Under this Business (Select Individual and Enter Contact Information)
Individual:  ☐  Veterinarian           ☐  Biologist         ☐  Animal Health Technician            ☐  Other (Specify)
 Salutation:

First Name:
Middle Name:

Last Name:

Individual Email Address(s) (To be included in all reports submitted):
Phone Number:
National Veterinary Accreditation Number (Optional): 
Individual:  ☐  Veterinarian           ☐  Biologist         ☐  Animal Health Technician            ☐  Other (Specify)
 Salutation:

First Name:
Middle Name:

Last Name:

Individual Email Address(s) (To be included in all reports submitted):

Phone Number:
National Veterinary Accreditation Number (Optional):
Individual:  ☐  Veterinarian           ☐  Biologist         ☐  Animal Health Technician            ☐  Other (Specify)
 Salutation:

First Name:
Middle Name:

Last Name:

Individual Email Address(s) (To be included in all reports submitted):

Phone Number:
National Veterinary Accreditation Number (Optional):
Individual:  ☐  Veterinarian           ☐  Biologist         ☐  Animal Health Technician            ☐  Other (Specify)
 Salutation:

First Name:
Middle Name:

Last Name:

Individual Email Address(s) (To be included in all reports submitted):

Phone Number:
National Veterinary Accreditation Number (Optional):
Individual:  ☐  Veterinarian           ☐  Biologist         ☐  Animal Health Technician            ☐  Other (Specify)
 Salutation:

First Name:
Middle Name:

Last Name:

Individual Email Address(s) (To be included in all reports submitted):

Phone Number:
National Veterinary Accreditation Number (Optional):
Comments/Additional Instructions:

□  This record is no longer needed; remove it from your active files.
Return updated forms via one of the following ways:
Email: [email protected]
Fax Number: 515-337-7022
Mail: USDA/APHIS/VS/National Veterinary Services Laboratories | Attn: LIMS Contact Update | 1920 Dayton Ave. | Ames, IA 50010
VS FORM 4-10
JUN 2024