Poultry Conveyance Request Form

Instruction

GDA will review the request within 3 business days. Please submit requests in a timely manner. We thank you for your cooperation.

Section 1:General Information Include the date(s) and time(s) the movement(s) will begin and end, name of requestor, date of request, Street Address and whether the shipment will be interstate or intrastate.

Section 2:Point of Origin Include location name, address, premise I.D., company name, type of facility, and whether or not it is within the surveillance zone.

Section 3:Point of Destination Include location name, address, premise I.D., company name, type of facility, and whether or not it is within the surveillance zone

Section 4:Point of Contact (Primary) Include contact name, title, company name, phone number, and email address.

Section 5:Point of Contact (Secondary) Include contact name, title, company name, phone number, and email address.

Section 6:Product Being Moved Include the type of product and quantity.

Section 7:Additional Information : Include the appropriate Information.

By submitting this request, you agree to meet Georgia’s movement requirements prior to any movement taking place. Failure to meet Georgia’s movement requirements can result in denial of future movement requests as well as civil and/or criminal penalties. Test results should be emailed to gapoultrypermits@agr.georgia.gov.

*Indicates required field

Section 1: General Information

Name of Requestor*

Date of Request*

Date & Time Movement Started*

Date & Time Movement End*

Is Movement for?*

Interstate Intrastate

Name of shipping company conducting the movement

Street Address*

City*

State*

Zip Code*

Section 2: Point of Origin

Location Name*

Physical Address*

City*

State*

Zip Code*

Premise I.D

Is location within the Surveillance Zone ?*

Company Name

Type of Facility

Biosecurity Plan Implemented ?*

Biosecurity Measures:

Section 3: Point of Destination

Location Name*

Physical Address*

City*

State*

Zip Code*

Premise I.D

Is location within the Surveillance Zone?*

Company Name

Type of Facility

Biosecurity Plan Implemented ?*

Biosecurity Measures:

Section 4: Point of Contact (Primary)

Contact Name*

Contact Title*

Company Name

Phone number*

Email Address for Notification*

Section 5: Point of Contact (Secondary)

Contact Name*

Contact Title*

Company Name

Phone number*

Email Address to send Notification*

Section 6 :Product Being Moved

Type*

Quantity*

Section 7: Additional Information

Route to Destination (If you need to change the route please notify gapoultrypermits@agr.georgia.gov before traveling.)

Has this flock been diagnosed with Avian Influenza by serology or PCR?

Failure to submit test results in a timely manner will slow the approval time.

Most Recent AI Test Result

Test Result Date

Laboratory Name

Laboratory Accession Number

Acknowledgement (Initial applicable boxes)

I hereby swear and affirm that the information contained herein is accurate and reliable at the time of submission. I understand and acknowledge that failure to submit required test results or meet the terms of Georgia’s movement requirements will result in denial of future movements and/or additional civil and/or criminal action.