* This is a required field.
*10. KIND AND AMOUNT OF MATERIAL DESIRED:
NC DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
MEAT AND POULTRY INSPECTION DIVISION
INSTRUCTIONS: After completion submit by mail or fax to:
Director
NC Department of Agriculture and Consumer Services
Meat and Poultry Inspection Division
Agriculture Building
1001 Mail Service Center
Raleigh, North Carolina 27699-1001
FAX: (919) 715-0246
*1. NAME: 2. ORGANIZATION: *3. DATE:
*4. TELEPHONE NUMBER:
6. FAX NUMBER:
*5. ADDRESS:
REQUESTER INFORMATION
ESTABLISHMENT(S) WHERE SPECIMENS ARE TO BE OBTAINED
APPLICATION TO OBTAIN
SPECIMENS FROM OFFICIAL ESTABLISHMENTS
*8. NAME: *9. CITY:
The above applicant desires the following specimens of diseased, condemned, or inedible material, including embryos and specimens of animal or
poultry parasites described below. Consent of the official establishment has been obtained by the applicant to remove specimens.
*11. INDICATE PURPOSE OF COLLECTING SPECIMENS:
Education Research Pharmaceutical Experimental
Other (Specify)
*12. DESCRIBE USE TO BE MADE OF SPECIMENS:
The applicant agrees that the collection and handling of this material shall be at such time and place and in such a manner as not to interfere with
the inspection or to cause any objectionable condition.
13. APPLICANT'S SIGNATURE: 14. APPLICANT'S TITLE
MPIS Form 5f (rev 3/6/13)
7. EMAIL ADDRESS:
