Continuation Form - Section B

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 xxxxx

Continuation Page of continuation pages

SECTION B continuation (Additional Senders of Imported Biological Agents) Sender #2
1. Sender’s Last Name		2. First Name		3. MI	4. Organization
5. Physical Address Outside of the U.S. (NOT a post office box)			6. City			7. State/Prov.		8. Country	9. Postal Code
10. Telephone	11. Fax						12. Email
Sender #3
1. Sender’s Last Name		2. First Name		3. MI	4. Organization
5. Physical Address Outside of the U.S. (NOT a post office box)			6. City			7. State/Prov.		8. Country	9. Postal Code
10. Telephone	11. Fax						12. Email
Sender #4
1. Sender’s Last Name		2. First Name		3. MI	4. Organization
5. Physical Address Outside of the U.S. (NOT a post office box)			6. City			7. State/Prov.		8. Country	9. Postal Code
10. Telephone	11. Fax						12. Email
Sender #5
1. Sender’s Last Name		2. First Name		3. MI	4. Organization
5. Physical Address Outside of the U.S. (NOT a post office box)			6. City			7. State/Prov.		8. Country	9. Postal Code
10. Telephone	11. Fax						12. Email
Sender #6
1. Sender’s Last Name		2. First Name		3. MI	4. Organization
5. Physical Address Outside of the U.S. (NOT a post office box)			6. City			7. State/Prov.		8. Country	9. Postal Code
10. Telephone	11. Fax						12. Email
Sender #7
1. Sender’s Last Name		2. First Name		3. MI	4. Organization
5. Physical Address Outside of the U.S. (NOT a post office box)			6. City			7. State/Prov.		8. Country	9. Postal Code
10. Telephone	11. Fax						12. Email
Sender #8
1. Sender’s Last Name		2. First Name		3. MI	4. Organization
5. Physical Address Outside of the U.S. (NOT a post office box)			6. City			7. State/Prov.		8. Country	9. Postal Code
10. Telephone	11. Fax						12. Email

CDC Form 0.753 (Continuation), Revised January 2014