This permit ideniities re!>tricled animals moved for quarantine/slaughief purposes The inloiination is needed to identify disease infected/ 

 exposed animals thai aie moved to specific locations m oider to control and prevent spiead of the disease (9 CFR 71 through 85) 



See reverse side tor additional information 



US DEPARTMENT OF AGRICULTURE 



ANIIMAL AND PLANT HEALTH INSPECTION SERVICE 



VETERINARY SERVICES 



PERMIT FOR MOVEMENT OF RESTRICTED ANIMALS 



USE A SEPARATE FORM FOR EACH SPECIES 



FORM APPROVED 

 0MB NO 0579-0051 



No. E 



5 STATE WHERE ISSUED 



1. NAME AND ADDRESS OF SHIPPER OR CONSIGNOR (Include Zip Code) 



6. MOVEMENT TO BE 



□ INTERSTATE □ INTRASTATE 



7. MOVEMENT FOR 



□ quarantine □slaughter 



8. DISEASE 



2. CONSIGNEE (Destination Name and Address, include Zip Code) 



9. STATUS OF ANIMALS 



No No Olhei 



No 

 Reactoi 



Exposed 



10. STATUS OF HERD OF ORIGIN 



(Specify) 



11. STATUS OF AREA OF ORIGIN 



3. MOVED FROM (Name and Locafion at Premise it ottier than rtem 1 above) 



12. NO. ANIMALS IN THIS 

 SHIPMENT 



13. SPECIES fOneon/y> 



4. NAME AND ADDRESS OF OWNER AT TIME CONDITION DIAGNOSED 



14. TRANSPORTATION VEHICLE LICENSE NO. OR OTHER IFENTIFICATION NO. 



15 SEAL NO 



VALID ONLY FOR ABOVE DESTINATION 



16 VEHICLE REQUIRED TO BE CLEANED AND 

 DISINFECTED AT DESTINATION 



□ yes 



□ no 



(II Yes. Items 32. 33, and 34 are Applicable) 



1 7 ANIMALS TO BE MOVED 



COMPLETE 

 EAR TAG NO 



BREED 



SEX 



DISEASE 

 BRAND 



OTHER IDENTIFICATION 

 (Complete No) 



COMPLETE 

 EAR TAG NO 



BREED 



SEX 



DISEASE 

 BRAND 



OTHER IDENTIFICATION 

 (Complete No.) 



















































































































































































































1 certify thai 1 fiave inspected the animals described on this permil and lind them eligible lo move in accordance with ihe requirements of State and Federal 

 regulations 



18. SIGNATURE OF INSPECTOR 



19 DATE ISSUED 



20. TIME ISSUED 



VOID AFTER 















21. DATE 



22. TIME 



WARNING TO OWNER, SHIPPER AND TRUCKER - LIVESTOCK MUST BE DELIVERED TO CONSIGNEE WITHOUT DIVERSION 



I understand that it is a violation ol Federal law lo move the animals identified herein inteistate except in accordance with the provisions ol applicable Federal 

 Regulations l also understand that such animals must comply with existing state laws and regulations governing movement ol livestock and poultry I have arrariged 

 01 Will artange tor a copy of this permit to accompany Ihe interstate shipment and be delivered with the above described animals 



23. SIGNATURE OF OWNER OF SHIPPER 



24. TITLE 



□ oVi/NER I [shipper 



25. DATE SIGNED 



I certify that the animals described on this permit were received and slaughteried/guaranlined in accrodance with the requirements of the Stale and Federal regulations 

 on the date indicated m item 29 



26. PLACE ANIMALS RECEIVED 



27. DATE ANIMALS ARRIVED 



28. NO ANIMALS RECEIVED 



29. DATE SLAUGHTERED/QUARANTINED 



30. DATE AND TIME 

 SEALS BROKE 



31. AUTHORIZED SIGNATURE 



32. DATE CLEANED AND 

 DISINFECTED (il 

 required) 



33 SIGNATURE OF INSPECTOR 



34. DATE SIGNED 



VS FORM 1-27 

 (JUN 89) 



Previous edition may be used 



PART 1 - TO ACCOMPANY SHIPMENT 



16-3 



