This certificate is authorized by law (21 USC 1 12). While you are not required to 

 respond, no health certificate can be validated unless the data required are provided. 



See reverse side for 

 additional 0MB information 



FORM APPROVED 0MB NO 0579-0048 



U.S. DEPARTMENT OF AGRICULTURE 



Animal and Plant Health Inspection Service 

 Veterinary Services 



CERTIFICATE FOR POULTRY OR HATCHING EGGS FOR EXPORT 



1 . DATE OF SHIPMENT 



No A 



2. NAME & ADDRESS OF EXPORTER (IPClude ZIP COds) 





3 NAME & ADDRESS OF IMPORTER 



Fips STATE CODE (for USDA USB only-see reverse} 













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FIPS COUNTRY CODE (for USDA USB only) 



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5. VARIETY, STRAIN 

 OR TRADE NAME 



6. PRODUCT 

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7. SEX 



(XO/-/) 



B. TYPE (Intended use) 



(X 0/- /) 



9. NPIP APPROVAL 





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10 NPIP CLASSIFICATION - U.S. 



[x.or /) 



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12. CHECK APPROPRIATE CERTIFICATION BELOW (A OR B) 



LJ *• Certificate for Hatching Eggs and Newly Hatctied Poultry, which have not been fed or watered This is to certify thai: (1) the flock or flocks and ih.^ 

 hatchery or hatcheries from which the above-described hatching eggs or newly hatched poultry originated were inspected by me or another accrediled 

 veterinarian within 30 days prior to shipment of atxjve hatching eggs or setting of eggs for above shipment of day old chicks and found free from evidence 

 of communicable diseases and insofar as can be determined have not been exposed to Newcastle disease, fowl plague, fowl typhoid, ornithosis, and 

 pullorum disease, (2) during the usual routine inspection of the flock or flocks there was no visible evidence of communicable diseases observed on the 

 inspection dates listed in item 13 below; (3) the National Poultry Improvement Plan classification is as indicated in item 9 above; and (4) the prospective 

 exporter has been advised that the hatching eggs must be clean and that the shipment must be made in new, clean containers. 



I I B. Certificate (or Poultry other than Newly Hatched Poultry Specified in Certificate A This is to certify that; (1) on this date all poultry shown in item 5 

 atxive, including all other poultry maintained in the flock, were inspected by me on the premises of origin within the past 30 days and found free from 

 evidence of infectious and contagious diseases and insofar as can be determined have not been exposed to Newcastle disease, fowl plague, fowl typhoid, 

 ornithosis, and pullorum disease, and (2) the prospective exporter has been advised that shipment must be made in new containers or clean containers 

 which have been properly cleaned and disinfected 



I 3. REMARKS OR ADDITIONAL INFORMATION (if needed) 



USDA VETERINARY SEAL C/yz-e^y/V-erfy 



14. TYPED NAME OF ISSUING VETERINARIAN 



IS. SIGNATURE OF ISSUING VETERINARIAN 



le. STATUS Ql. State □ 2. Federal □ 3. Accredited 



17 DATE ISSUED 



Mo Da Yr 

 1 1 



IB. SIGNATURE OF ENDORSING FEDERAL VETERINARIAN lit required) 



19. DATE ENDORSED 



Mo Da Yr 

 1 1 



VS FORM 17-6 Previous edition is obsolete 

 (SEPT 95) 



TO ACCOMPANY SHIPMENT 



16-37 



