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DEPARTMENT OF AGRICULTURE - DIVISION OF ANIMAL HEALTH

HPAI Permit Request Form

Permitting Procedure for Importation of Poultry, Hatching Eggs or Poultry Waste from Highly Pathogenic Avian Influenza (HPAI) States

Only poultry or hatching eggs moving into New Jersey live bird markets, from HPAI states, require a permit and 72-hour test. The collection date, collection time, laboratory result, laboratory accession number and laboratory name must be recorded on the CVI accompanying the shipment. A copy of the laboratory report must also accompany the shipment. No poultry waste shall be imported from HPAI states, without prior approval and permit issued by the State Veterinarian. For information about testing please refer to the N.J.A.C. 2:3-7.4 (b) at http://www.nj.gov/agriculture/divisions/ah/pdf/NJACChapter3.pdf

This form is to be used to facilitate the receipt of information. Submission of this form is not a permit for movement.

Please call the Division of Animal Health at 609-671-6400 with any questions.

* REQUIRED FIELD

Caller/Requester Information

First Name

Last Name

Phone

Fax

Email

Relationship to Shipment

Shipment Origin

Premises Name

Name of Person Responsible for Shipment

Phone

Fax

Premises Physical Location

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

If the premises mailing address is the same as the premises physical location, check the box.

Premises Mailing Address (if different from premises physical location above)

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Shipment Information

Quantity

Shipment Date

Live Poultry

Live Poultry Quantity

Live Poultry Shipment Date

Empty Field

Hatching Eggs

Hatching Eggs Quantity

Hatching Eggs Shipment Date

Empty Field

Poultry Waste

Poultry Waste Quantity

Poultry Waste Shipment Date

Empty Field

Shipment Destination

Choose Number of Shipment Destinations Value is not selected

Shipment Destination #1

Premises Name

Name of Person Responsible for the Shipment

Phone

Fax

Premises Physical Location #1

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Premises Mailing Address #1 (if different from premises physical location)

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Shipment Destination #2

Premises Name

Name of Person Responsible for the Shipment

Phone

Fax

Premises Physical Location #2

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Premises Mailing Address #2 (if different from premises physical location)

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Shipment Destination #3

Premises Name

Name of Person Responsible for the Shipment

Phone

Fax

Premises Physical Location #3

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Premises Mailing Address #3 (if different from premises physical location)

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Shipment Destination #4

Premises Name

Name of Person Responsible for the Shipment

Phone

Fax

Premises Physical Location #4

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Premises Mailing Address #4 (if different from premises physical location)

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Shipment Destination #5

Premises Name

Name of Person Responsible for the Shipment

Phone

Fax

Premises Physical Location #5

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Premises Mailing Address #5 (if different from premises physical location)

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Shipment Destination #6

Premises Name

Name of Person Responsible for the Shipment

Phone

Fax

Premises Physical Location #6

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Premises Mailing Address #6 (if different from premises physical location)

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Shipment Destination #7

Premises Name

Name of Person Responsible for the Shipment

Phone

Fax

Premises Physical Location #7

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Premises Mailing Address #7 (if different from premises physical location)

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Shipment Destination #8

Premises Name

Name of Person Responsible for the Shipment

Phone

Fax

Premises Physical Location #8

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Premises Mailing Address #8 (if different from premises physical location)

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Shipment Destination #9

Premises Name

Name of Person Responsible for the Shipment

Phone

Fax

Premises Physical Location #9

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Premises Mailing Address #9 (if different from premises physical location)

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Shipment Destination #10

Premises Name

Name of Person Responsible for the Shipment

Phone

Fax

Premises Physical Location #10

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Premises Mailing Address #10 (if different from premises physical location)

Number

Street Name

City

Zip Code

Premises ID

GPS Coordinates

Submission of Lab Results

Upload a Copy of the Lab Results

Applicant Signature

The undersigned hereby applies for a permit to import poultry waste, live poultry or hatching eggs. In signing this form, I certify the responses/entries are true. I am aware if any of the responses/entries are willfully false, I am subject to punishment. I certify that I will comply with all required New Jersey and federal animal health laws, regulations, and directives. I will notify the New Jersey Department of Agriculture of any change in the foregoing information before shipping and changes in shipment origin, information and/or destination require a new permit request.

Signature

Date Signed

Full Name

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Highly Pathogenic Avian Influenza Permit Request

Caller/Requester Information

Shipment Origin

Shipment Information

Shipment Destination

Submission of Lab Results

Applicant Signature