FIMA Form 1815

DEPARTMENT OF HEALTH AND HUMAN SERVICES

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

FOOD AND DRUG ADMINISTRATION

(Place)

(Date)

Secretary of Health and Human Services
Washington, D.C.
Sir:
I hereby certify that
(Name of applicant for permit)

(Address of applicant)

whose application for a permit to ship or transport milk and/or cream into the Untied States is attached hereto,
has complied with the applicable provisions of the Federal Import Milk Act, as shown by the attached reports,
and that the signers* of such reports,

(Name of signer of report)

(Title or veterinary degrees)

(Name of signer of report)

(Title or veterinary degrees)

(Name of signer of report)

(Title or veterinary degrees)

(Name of signer of report)

(Title or veterinary degrees)

acted under my supervision and are authorized to make the required inspections and examinations.

(Signature of duly accredited official of foreign government
or State of the United States or municipality thereof)

(Date)

*If space is too limited to list names of all inspectors and veterinarians signing attached reports, the back of this certificate may be
used.
NOTE: This form must be filed when applicant desires to obtain a permit based on a certificate of a duly accredited official of an
authorized department of a foreign government and / or of any State of the United States or municipality thereof. There must be
attached to it, as part thereof, the signed application for a permit and the necessary reports of veterinarians and inspectors.

FORM FDA 1815 (12/10)

CERTIFICATE /TRANSMITTAL FOR AN APPLICATION

PSC Graphics (301) 443-6740

EF

Public reporting burden for this collection of information is estimated to average .5 hour per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and 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
1350 Piccard Drive, Room 400
Rockville, MD 20850
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 1815 (12/10)