Application for Permit to Import or Transfer Live Bats

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

APPLICATION FOR PERMIT TO IMPORT OR TRANSFER LIVE BATS

FORM APPROVED OMB NO. 0920-0199 EXP DATE MM/DD/YYYY

Guidance for completing this form is available at http://www.cdc.gov/od/eaipp/importApplication/. This form may be submitted by mail, fax, or email attachment to the Centers for Disease Control and Prevention, Import Permit Program. Mailing Address: 1600 Clifton Road NE, Mailstop A-46, Atlanta, GA 30333. Fax: 404-718-2093. E-mail: [email protected]. Telephone: 404-718-2077.

Please submit completed form only once by either email, fax, or mail

SECTION A – PERSON REQUESTING PERMIT IN U.S.A.

1. Permittee’s Last Name

2. Permittee’s First Name

3. MI

4. Permittee’s Organization

5. Address (NOT a post office box)

6. City

7. State

8. Zip Code

9. Permittee’s Telephone Number

10. Permittee’s FAX Number

11. Permittee’s E-mail

12. Secondary Contact’s Name

13. Secondary Contact’s Telephone Number

14. Secondary Contact’s Email Name

SECTION B – SOURCE OF BATS

1. Last name of Sender

2. First

3. MI

4. Organization

5. Address (NOT a post office box)

6.City

7.State/Prov

8. Postal Code

9. Country

10. Telephone

11. FAX

12. E-mail

SECTION C – DESCRIPTION OF BATS

Indicate Species of Bats and Total Number to be Imported ( Additional sheets attached):

1. Genus/Species of Bat

2. Common Name of Bat Species

3. Family

4. Total Number of Bats

5.  Wild-caught (indicate where bats were obtained, e.g., name of cave, game reserve, town, or province:_____________________ ________________________________________________________________________________________________________)  Captive bred

6. Proposed use of bats:  Education  Exhibition  Scientific Other (Describe:_____________________________________) Note: If use is “scientific research,” attach research proposal and IACUC documentation

7. Describe how bats will be used ( Additional sheets attached):

8. Estimated completion date of work:

9. Will animals be captive bred?  Yes  No

10. Intended final disposition:  Euthanasia  Transfer  Institutional use in perpetuity

APPLICATION FOR PERMIT TO IMPORT OR TRANSPORT LIVE BATS FORM APPROVED

OMB NO. 0920-0199

EXP DATE MM/DD/YYYY

Page 2 of 2

SECTION D – TYPE OF PERMIT AND SHIPMENT INFORMATION
1.  Importation into U.S.  Transfer within the U.S			2. U.S. port(s) of entry (if known):
3. Size of transport container(s):			4. Number of bats per container(s):
5. Method of transport:  Air  Surface  Other (Explain:_________________________________________________)
SECTION E – Biosafety measures for facilities and technical personnel
1. Description of 180-day quarantine laboratory facilities and equipment: Animal Biosafety level (ABSL) of 180-day quarantine facility (See instructions):  ABSL1  ABSL2  ABSL3  ABSL4
2. Description of post-quarantine housing: Biosafety level of post-quarantine facility (See instructions):  ABSL1  ABSL2  ABSL3  ABSL4
3. Name of attending Veterinarian:		4. Affiliation
5. Address (NOT a post office box)		6. City		7. State	8. Zip Code
9. Telephone	10. FAX	11. E-mail
12. Describe the qualifications and experience of technical personnel handling the bats:
13. Have all personnel that will be working with bats received rabies immunizations? Yes  No (If no, explain:________________ ____________________________________________________________________________________________________________)

I hereby certify that the information submitted in this application is complete and accurate to the best of my knowledge and belief. I agree to comply with the conditions listed in the application and all restrictions and precautions that may be specified in the permit, in addition to all applicable regulations which govern this transfer. I understand that failure to comply with the importation requirements may subject me to criminal penalties pursuant to 42 U.S.C. 271. I understand that any false statement made in this application may subject me to criminal penalties pursuant to 18 U.S.C. 1001.

SECTION F – signature of permittee
1. APPLICANT (Print Name)	2. SIGNATURE	3. TITLE	4. DEGREE(S)	5. DATE SIGNED (MM/DD/YYYY)

Public recording burden of this collection of information is estimated to average 20 minutes 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 30333; ATTN: PRA ( 0920-0199)

CDC 0.1345

REV. 02/04