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FORM APPROVED: APPLICATION FOR REGISTRATION FOR POSSESSION, USE, (Department of Health and Human Services)

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File type: PDF

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APPLICATION FOR
REGISTRATION FOR POSSESSION,
USE, AND
TRANSFER OF SELECT AGENTS AND TOXINS
(APHIS/CDC FORM 1)
FORM APPROVED
OMB NO. 0579-0213
OMB NO. 0920-0576
EXP DATE 10/31/2020
Section 1A - Entity Information
This submission is:
A new registration
An update to an existing registration
A renewal Date:
ENTITY INFORMATION
Entity Application Number (e.g., CDC030001):
Current Registration Number (e.g., A00000000-0000):
Entity Name:
Physical Address (NOT a post office box):
City:
State:
Zip Code:
Additional Physical Address(es):
Type Of Entity:
Academic (Private) Academic (State)
Commercial (Profit)
Government (Federal)
Government (State/Local) Private (Non Profit)
RESPONSIBLE OFFICIAL INFORMATION
Last Name:
First Name:
DOJ Number: Date of Birth:
Tier 1 Access:
Business E-mail Address:
Title (e.g., Biosafety Officer):
Business Telephone #:
Business Fax #:
Emergency Telephone #:
Mailing Address (NOT a post office box): City:
State:
Zip Code:
ALTERNATE RESPONSIBLE OFFICIAL INFORMATION
Last Name:
First Name:
DOJ Number: Date of Birth:
Tier 1 Access:
Business E-mail Address: Title (e.g., Biosafety Officer):
Business Telephone #: Business Fax #:
Emergency Telephone #:
Mailing Address (NOT a post office box): City:
State:
Zip Code:
Page 1 of 4
This submission is:
A new registration
An update to an existing registration A renewal
Date:
Entity Name:
Section 1A - Entity Information
2nd ALTERNATE RESPONSIBLE OFFICIAL INFORMATION
Last Name:
First Name:
DOJ Number: Date of Birth:
Tier 1 Access:
Business E-mail Address: Title (e.g., Biosafety Officer):
Business Telephone #: Business Fax #:
Emergency Telephone #:
Mailing Address (NOT a post office box): City:
State:
Zip Code:
3rd ALTERNATE RESPONSIBLE OFFICIAL INFORMATION
Last Name:
First Name:
DOJ Number: Date of Birth:
Tier 1 Access:
Business E-mail Address: Title (e.g., Biosafety Officer):
Business Telephone #: Business Fax #:
Emergency Telephone #:
Mailing Address (NOT a post office box): City:
State:
Zip Code:
4th ALTERNATE RESPONSIBLE OFFICIAL INFORMATION
Last Name:
First Name:
DOJ Number: Date of Birth:
Tier 1 Access:
Business E-mail Address: Title (e.g., Biosafety Officer):
Business Telephone #: Business Fax #:
Emergency Telephone #:
Mailing Address (NOT a post office box): City:
State:
Zip Code:
Page 2 of 4
This submission is:
A new registration
An update to an existing registration A renewal
Date:
Entity Name:
Section 1A - Entity Information
5th ALTERNATE RESPONSIBLE OFFICIAL INFORMATION
Last Name:
First Name:
DOJ Number: Date of Birth:
Tier 1 Access:
Business E-mail Address: Title (e.g., Biosafety Officer):
Business Telephone #: Business Fax #:
Emergency Telephone #:
Mailing Address (NOT a post office box): City:
State:
Zip Code:
OWNER / CONTROLLER INFORMATION (If Applicable)
Last Name:
First Name:
DOJ Number: Date of Birth:
Tier 1 Access:
2nd OWNER / CONTROLLER INFORMATION (If Applicable)
Last Name:
First Name:
DOJ Number: Date of Birth:
Tier 1 Access:
3rd OWNER / CONTROLLER INFORMATION (If Applicable)
Last Name:
First Name:
DOJ Number: Date of Birth:
Tier 1 Access:
4th OWNER / CONTROLLER INFORMATION (If Applicable)
Last Name:
First Name:
DOJ Number: Date of Birth:
Tier 1 Access:
Page 3 of 4
This submission is:
A new registration
An update to an existing registration A renewal
Date:
Entity Name:
Section 1B - Certification of Responsibility
I hereby certify that I have been designated as the Responsible Official or the Alternate Responsible Official(s) for the
institution/organization listed above, that I am authorized to bind the institution/organization, and that the information supplied
in this registration package is, to the best of my knowledge, accurate and truthful. The institution/organization listed above
meets the requirements specified in 42 CFR Part 73 and/or 7 CFR Part 331 and/or 9 CFR Part 121, is equipped and capable
of safely and securely handling the agent(s), and will use or transfer these agents solely for purposes authorized by 42 CFR
Part 73 and/or 7 CFR Part 331 and/or 9 CFR Part 121.
I understand that submission of a false statement and/or failure to comply with the provisions of the applicable regulations (42
CFR Part 73 and/or 7 CFR Part 331 and/or 9 CFR Part 121) may result in the immediate revocation of this entity's registration,
a civil penalty of up to $500,000 for each violation, and a criminal penalty and/or imprisonment up to five years for each
violation. (7 USC 8401; 18 USC 175, 175B, 1001, 3559, 3571; 42 USC 262a).
Responsible Official Signature
Date
Responsible Official Name
Alternate Responsible Official Signature Date
Alternate Responsible Official Name
2nd Alternate Responsible Official Signature Date
2nd Alternate Responsible Official Name
3rd Alternate Responsible Official Signature Date
3rd Alternate Responsible Official Name
4th Alternate Responsible Official Signature Date
4th Alternate Responsible Official Name
5th Alternate Responsible Official Signature Date
5th Alternate Responsible Official Name
Page 4 of 4
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FORM APPROVED: APPLICATION FOR REGISTRATION FOR POSSESSION, USE, (Department of Health and Human Services)

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Completed 25 January 2021

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