VS 4-10 NVSL Contact Information Update

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