VS Form 17-140: United States Origin Health Certificate 



General Information and Navigation Hints 



Begin by filling out the Consignor [shipper] and Con- 

 signee [receiver] information in blocks 1, 7, 8, 12, 13, 14, 

 and 16 (including DESTINATION COUNTRY and ENTER 

 CODE blocks, which arc not numbered thcmscKcsj. 

 Block-specific instructions follow where appropriate. 



Block 2 is not filled in by you; the form comes with a 

 preprinted unique number on it, and we have erased 

 that on purpose here. Block 3 cannot be filled in until 

 you know if you will need to use Form 17-140A, the 

 continuation sheet for Form 17-140. 



Next, fill in general information about this health 

 certificate: insert the date on which you are issuing the 

 certificate (block 4), the location where the shipment 

 is leaving the United States (blocks 5 and 6), and the 

 shipping method being employed (block 11 ). 



Indicate whether or not this shipment is of semen 

 (block 9) and if so, how many doses are being shipped 

 (block 10). 



Determine which nonpoulii) SPECIES is being shipped 

 (block 15). Check only ONE species and describe all 

 such animals on this Form 17-140. If the shipment 

 includes animals of other species, fill out a separate 

 Form 17-140 for each species and check the appropri- 

 ate species in block 15 on each form. [If the shipment 

 includes poultry, do not use Form 17-140: use Form 

 17-6 instead.] 



Fill in the FARM ORIGIN information (block 17) as spec- 

 ified on the form itself. Then determine which types of 

 tests you are certifv'ing and complete the blocks on the 

 central and right-hand parts of the form accordingly. 



in the CERTIFICATION BY ISSUING VETERINARIAN sec- 

 tion at the bottom of Form 17-140, you \s ill give in- 

 formation about yourself in blocks 20 and 21, fill in the 

 total number of animals on all sheets describing this 

 shipment in block 22, and sign your name in block 25. 



You will type or print the name o( the endorsing Fed- 

 eral veterinarian in block 24 and fill in the date he or 

 she endorses this certificate in block 19. The endorsing 

 Federal \'eterinarian must sign in block 23. 



Block-by-Block Instructions 



PAGE NO. [block 3] 



If all animals in this shipment can be described in the 

 space on this form, enter"! of 1" in block 3. If not, use 

 Form 17-140A (Continuation Sheet for the United 

 States Origin Health Certificate) to account for all 

 animals being shipped and enter " 1 of X" with "X" 

 standing for the total number of forms invoK'cd. 



DATE ISSUED [block 4] 



Enter the date the \eterinar\' inspection is completed. 



U.S. PORT OF EMBARKATION [block 5] 

 Enter the point of loading for export. 



STATE CODE [block 6] 



The code for the State where the pt)int of embarkation 

 is located. The FIPS State codes are provided on the 

 back of the last page in the carbon-pack tor this form. 



STATE CODE [block 13] 



The code for the State where the consignor [shipper] is 

 located. Again, consult the FIPS State codes listed on the 

 back of the last sheet in the carbon-pack for this form. 



16-38 



