Continuation Form - Section A

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

CONTINUATION PAGE FOR APPLICATION FOR PERMIT TO IMPORT INFECTIOUS BIOLOGICAL AGENTS INTO THE UNITED STATES

FORM APPROVED OMB NO. 0920-0199 EXP DATE xxxx

Continuation Page of continuation pages

SECTION A continuation (Other Persons Authorized to use Permit)
Permittee #2
1. Permittee’s Last Name	2. First Name			3. MI	4. Permittee’s Organization
5. Physical Address (NOT a post office box)			6. City				7. State	8. Zip Code
9. Permittee’s Telephone Number		10. Permittee’s Fax Number				11. Permittee’s Email
12. Secondary Contact’s Name		13. Secondary Contact’s Telephone Number				14. Secondary Contact’s Email
15. Will this individual be hand carrying the imported biological agent? Yes No
Permittee #3
1. Permittee’s Last Name	2. First Name			3. MI	4. Permittee’s Organization
5. Physical Address (NOT a post office box)			6. City				7. State	8. Zip Code
9. Permittee’s Telephone Number		10. Permittee’s Fax Number				11. Permittee’s Email
12. Secondary Contact’s Name		13. Secondary Contact’s Telephone Number				14. Secondary Contact’s Email
15. Will this individual be hand carrying the imported biological agent? Yes No
Permittee #4
1. Permittee’s Last Name	2. First Name			3. MI	4. Permittee’s Organization
5. Physical Address (NOT a post office box)			6. City				7. State	8. Zip Code
9. Permittee’s Telephone Number		10. Permittee’s Fax Number				11. Permittee’s Email
12. Secondary Contact’s Name		13. Secondary Contact’s Telephone Number				14. Secondary Contact’s Email
15. Will this individual be hand carrying the imported biological agent? Yes No
Permittee #5
1. Permittee’s Last Name	2. First Name			3. MI	4. Permittee’s Organization
5. Physical Address (NOT a post office box)			6. City				7. State	8. Zip Code
9. Permittee’s Telephone Number		10. Permittee’s Fax Number				11. Permittee’s Email
12. Secondary Contact’s Name		13. Secondary Contact’s Telephone Number				14. Secondary Contact’s Email
15. Will this individual be hand carrying the imported biological agent? Yes No

CDC Form 0.753 (Continuation), Revised January 2014