FIMA Form 1993

Form Approved: OMB No. 0910-0212
Expiration Date: June 30, 2012
See Reverse for OMB Statement

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION

APPLICATION FOR PERMIT TO SHIP OR TRANSPORT MILK AND/OR CREAM INTO THE UNITED STATES
NOTE:

Read regulations carefully before filling out this application. A separate application must be filled out for each establishment making direct
shipment to the United States. If additional space is required, continue on reverse referring to specific item being continued.
Application is hereby made by a permit to ship or transport milk and/or cream
into the United States as provided by the Federal Import Milk Act of February 15, 1927.

1. Shipper's name in full

2. Establishment location from which applicant ships

3. List names and locations of the dairy farm(s) from which the milk is obtained (Use separate sheet if necessary.)

4. Have the cows passed a tuberculin test applied by a duly authorized official veterinarian of the United States or of the
country in which milk or cream is produced, within one year previous to the time of the importation, showing that such
cows are free from tuberculosis?

YES

5. Have the cows producing milk or cream been subjected to a physical examination in the past year?
If "Yes", by whom?

YES

6. List the approximate number of cows furnishing the milk
supply proposed for importation.

NO

NO

7. List plant(s) and/or station(s)

YES

8. Does applicant reside in the United States and make collections of milk or cream by his own or hired conveyances which
transport the product to the United States?

NO

9. If the answer to Question 8 is "YES", list by name the dairy farms supplying milk to the collecting conveyances.

10. Usual means of transportation

a.

TRUCK

b.

RAILROAD

c.

OTHER (Specify)

11. Give location of customs office through which entry into the United States is made.

12. Are you the operator in the United States of a condensery or condenseries in which sterilization is a necessary process,
and which condensery or condenseries are within 15 miles of the point of production of the milk or cream?

YES

13. If the answer to Question 12 is "YES", do you wish to have waived the requirements of paragraph 4 of Section 2 of the
act when a permit is issued to you?

YES

NO

NO

14. If the answer to Question 12 is "YES", give name and location of such condensery or condenseries.

15. Are you the operator of or a producer shipping to a creamery or condensery in the United States within 20 miles of the
point of production of the milk? State whether operator or producer.

YES

16. If the answer to Question 15 is "YES", do you import raw milk for any purpose other than pasteurization, condensation,
or evaporation?

YES

NO

NO

17. If the answer to Question 15 is "YES", give names and locations of creameries or condenseries.

18. Name of milk or cream product involved

19.
Corporation

20. Title and signature of officer of corporation or
partnership

21. Address to which permit is to be sent

Partnership

FORM FDA 1993 (8/09)

PREVIOUS EDITION IS OBSOLETE

PSC Graphics (301) 443-1090

EF

Public reporting burden for this collection of information is estimated to average .5 hours per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden to:
Department of Health and Human Services
Food and Drug Administration
Office of Chief Information Officer (HFA-710)
5600 Fishers Lane
Rockville, MD 20857
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless
it displays a currently valid OMB control number.

FORM FDA 1993 (8/09)