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IED Portal

An Official Pennsylvania Government Website

Pennsylvania Department of Agriculture

PDA

PERMIT APPLICATION TO MOVE – POULTRY, EGGS & OTHER PRODUCTS

Contact Person At Origin Location Of Animals Or Products

First Name

*

Last Name

*

Contacts Email

**

Business Name

*

Phone

*

Physical Address of Origin

*

City

*

State

Zip Code

*

Premises ID

*

Contacts Mailing Address

*

Contact Person at Destination and Final Location of Animals or Products

First Name

*

Last Name

*

Contacts Email

**

Business Name

*

Phone

*

Physical Address of Destination

*

City

*

State

Zip Code

*

Premises ID

*

Contact’s Mailing Address

*

There are more than 1 destinations or stops on this route

*

There are more than 1 destinations or stops on this route NoThere are more than 1 destinations or stops on this route Yes

Product And Movement Information

Permit Area Class

Reason for Movement

Associated Species

Items to Permit

Item Class

Units of Items

Estimated # of units per shipment days

*

Estimated # of shipment days

*

Shipments Approx. Start Date

*

Shipments Approx. End Date

*

Notes

*

Collection Date #1

*

Accession #1

*

Collection Date #4

*

Accession #4

*

Collection Date #2

*

Accession #2

*

Collection Date #6

*

Accession #5

*

Collection Date #3

*

Accession #3

*

Collection Date #5

*

Accession #6

*

Owner Certification

REQUIRED:

Attached is the site-specific biosecurity plan patterned from the NPIP Standard E Biosecurity Plan Template for the premises of origin.

Attached are appropriate lab accession reports listed above, if available.

Date

*

Printed Name

*

Email

***

Phone

*

Address

*

City

*

State

Zip Code

*

Signature - This Space for Official Use Only

Approved

Testing Verified

Disapproved

No Testing Needed

Void

Approved Biosecurity Plan

Plan Submitted By

*

PENNSYLVANIA APPROVAL - The birds, eggs, or products listed in this shipment are approved for movement.

Date Approved

*

Permit No

*

Approving Authority

*

Comments

*

Attachment

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