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. Send comments regarding this burden statement or any other aspect of this information collection, including suggestions for reducing this burden, to [email protected].

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
Name of Business/Laboratory (Required):

OMB Approved
0579-0430
Exp. XX/XXXX

NVSL Contact Information Update
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:

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

Individual: ☐ Veterinarian
Salutation:

First Name:

☐ Biologist

Phone Number:

☐ Animal Health Technician

Middle Name:

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

Individual: ☐ Veterinarian
Salutation:

First Name:

☐ Biologist

Salutation:

First Name:

☐ Animal Health Technician

Middle Name:

☐ Biologist

Salutation:

First Name:

☐ Animal Health Technician

Middle Name:

☐ Biologist

Last Name:

Phone Number:

☐ Animal Health Technician

Middle Name:

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

Last Name:

Phone Number:

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

Individual: ☐ Veterinarian

Last Name:

Phone Number:

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

Individual: ☐ Veterinarian

Last Name:

Last Name:

Phone Number:

National Veterinary Accreditation
Number (Optional):

☐ Other (Specify)
National Veterinary Accreditation
Number (Optional):

☐ Other (Specify)
National Veterinary Accreditation
Number (Optional):

☐ Other (Specify)
National Veterinary Accreditation
Number (Optional):

☐ Other (Specify)
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