TO IMPORT BIOLOGICAL AGENTS OR VECTORS OF HUMAN DISEASE INTO THE

TO IMPORT BIOLOGICAL AGENTS OR VECTORS OF HUMAN DISEASE INTO THE

2 Pages · 2014 · 1.5 MB · English

SECTION D, Final Destination of Imported Biological Agent: 1. Is final destination of biological agent(s) different from address in Section A?

TO IMPORT BIOLOGICAL AGENTS OR VECTORS OF HUMAN DISEASE INTO THE free download

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service APPLICATION FOR PERMIT TO IMPORT INFECTIOUS BIOLOGICAL AGENTS INTO THE UNITED STATES FORM APPROVED OMB NO. 0920- 0199 EXP DATE 01/31/2017 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: 404-471-8333.E-mail: [email protected] Telephone: 404-7 18-2077. Application Number: Permit # issued (For Program use ONLY) Please submit completed form only once by either email , fax, or mai l SECTION A - Person Requesting Permit in U.S. (Permittee) 1.Permittee’s Last Name 2. Permittee’s First Name 3. MI 4. Permittee’s Organization 5. Physical 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 Email 12. Secondary Contact’s Name 13. Secondary Contact ’s Telephone Number 14. Secondary Contact ’s Email 15 . Will the permittee be the courier of the imported biological agent? Yes No 16. Will other members of the organization listed above, in Section A Block 4, be authorized to use the approved permit? No Yes if Yes 17. Check here if you have included a Continuation For m to list others authorized to use this permit SECTION B - Sender of Imported Infectious Biological Agent (s) or Vector(s) 1. Sender ’s Last Name ( Check if same as Sec A) 2. First Name 3. MI 4. Sender’s Organization 5.Physical Address Outside of the U.S. (NOT

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