Free Indiana Department of Natural Resources - Indiana

APPLICATION FOR PERMIT TO MOVE OR RELEASE LIVE PLANT PESTS AND PATHOGENS, WEEDS, & BENEFICIAL ORGANISMS
State Form 51859 (8-04)

Indiana Department of Natural Resources Division of Entomology & Plant Pathology 402 West Washington Street, Room W-290 Indianapolis, Indiana 46204-2739 Telephone: (317) 232-4120 Fax Number: (317) 232-2649

SECTION A ­ TO BE COMPLETED BY THE APPLICANT
1. NAME & ADDRESS (INCLUDE ZIP CODE) 5A. TYPE OF BENEFICIAL ORGANISM/PEST TO BE MOVED/RELEASED *
*This Permit does not authorize the introduction, importation, interstate, intrastate movement, or release into the environment of any genetically modified organisms or products. **

___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________
2. TELEPHONE NO. 3. FACSIMILE NO. 4. E-MAIL:

(

)______________________________ )_______________________________

BACTERIA EARTHWORM FUNGI INSECT MITE

NEMATODE WEED PROTOZOA VIRUS OTHER: ________

(

___________________________________________

**ARE ANY ORGANISMS ON THIS APPLICATION GENETICALLY MODIFIED? NO YES (PLEASE COMPLETE REVERSE) 5F. SHIPPED FROM 5G. ESTABLISHED
US? IN?

5B. SCIENTIFIC NAME

5C. CLASSIFICATION 5D. LIFE STAGE 5E. NO. OF SPECIMENS

5H. HOST(S)

________________________ ______________________ ________________ ________________________ ____________________ ___________ ___________ ____________ ________________________ ______________________ ________________ ________________________ ____________________ ___________ ___________ ____________ ________________________ ______________________ ________________ ________________________ ____________________ ___________ ___________ ____________ ________________________ ______________________ ________________ ________________________ ____________________ ___________ ___________ ____________ ________________________ ______________________ ________________ ________________________ ____________________ ___________ ___________ ____________ ________________________ ______________________ ________________ ________________________ ____________________ ___________ ___________ ____________

6 WHAT HOST MATERIAL OR SUBSTITUTES WILL ACCOMPANY EACH BENEFICIAL ORGANISM/PEST

7. DESTINATION

8. PORT OF ARRIVAL

9. DATE OF ARRIVAL

10. NO. OF SHIPMENTS

11. SUPPLIER

12. METHOD OF SHIPMENT

13. INTENDED USE (BE SPECIFIC, ATTACH OUTLINE OF INTENDED RESEARCH)

14. METHODS TO BE USED TO PREVENT ESCAPE 16. PLEASE ANSWER EACH OF THE FOLLOWING

15. METHOD OF FINAL DISPOSITION

· · · ·

THE ABOVE ORGANISMS ARE REGULATED IN OTHER STATES OR COUNTRIES? THESE ORGANISMS ARE/WERE COVERED UNDER A FEDERAL PPQ FORM 526?

NO NO

YES, WHERE? _____________ YES, #? ______________________

DOCUMENTATION WAS PREVIOUSLY SUBMITTED TO OTHER AGENCIES OR BIOSAFETY COMMITTEES FOR REVIEW? NO YES, ELABORATE _____________________________________________________________________________________ ADDITIONAL DOCUMENTATION ACCOMPANIES THIS APPLICATION? NO YES, # OF PAGES? ___________________

17. I/We agree to supply any additional information, which may be requested in considering this application, and to comply with the safeguards printed on the reverse of this
form. I/We understand that a permit may be subject to other conditions specified in Section B. Application subject to the conditions of 312 IAC 18-3-15.

SIGNATURE OF APPLICANT: ______________________________________________________

DATE: _____________________________

SECTION B ­ TO BE COMPLETED BY STATE OFFICIAL
IS FURTHER REVIEW / INFORMATION REQUIRED? NO YES _________________
DATE VALID UNTIL PERMIT NUMBER

COMMENTS:

SIGNATURE OF IDNR: ENTOMOLOGY & PLANT PATHOLOGY DIRECTOR

APPLICATION FOR PERMIT TO MOVE OR RELEASE LIVE PLANT PESTS AND PATHOGENS, WEEDS, & BENEFICIAL ORGANISMS
SECTION C ­ TO BE COMPLETED BY THE APPLICANT
1. IS THIS ORGANISM, AT THE SPECIES LEVEL, ESTABLISHED IN THE UNITED STATES?

YES
2.

NO

IF YES, WHERE?__________________________________________________________

HAS THE APPLICANT RECEIVED AN APPROVED USDA PERMIT DERIVED FROM THE SUBMITTAL OF APHIS FORM 2000?

YES
3.

NO

(IF YES, PLEASE PROVIDE A COPY)

DESCRIBE ANY ECOLOGICAL ATTRIBUTES WHICH ARE DIFFERENT FROM THE NON-MODIFIED ORGANISM

____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________
4. DOES THE ORGANISM INTER-BREED WITH SPECIES ESTABLISHED IN INDIANA?

YES

NO

IF YES, WITH?_____________________________________________________________

INDIANA CODE: TITLE 14, ARTICLE 24, CHAPTER 3 ­ RULES The commission shall adopt rules under IC 4-22-2 to implement this article. (IC 14-24-3-1) The commission shall provide standards for operation and maintenance within an infested area declared under IC 14-244. (IC 14-24-3-2) The commission shall establish standards for the control of pests and pathogens. (IC 14-24-3-3) The commission shall regulate nurseries, nurserymen, and dealers. (IC 14-24-3-4) The commission may establish special service fees under IC 14-24-10-2. (IC 14-24-3-5) The commission may declare species or subspecies to be pests or pathogens. This identification must include any species or subspecies of bee that may endanger the bee and honey industry. (IC 14-24-3-6) The commission shall develop quarantine regulations needed to carry out this article. (IC 14-24-3-7) The commission shall establish measures for the protection of the bee and honey industry in Indiana. (IC 14-24-3-8) The commission shall establish standards for determining expenses and attorney's fees under IC 14-24-11-5. (IC 14-243-9) STANDARD SAFEGUARDS OF PERMIT 1. 2. 3. 4. 5.
6. 7.

All pests must be shipped in sturdy, escape-proof containers. Upon receipt of pests, all packing material media, substrate, soil, and shipping containers shall be sterilized or destroyed immediately after removing pests. Pests shall be kept only within the laboratory or designated area at the permittee's address. No living pests kept under this permit shall be removed from confined area except by prior approval from State regulatory officials. Without prior notice and during reasonable hours, authorized State regulatory officials shall be allowed to inspect the conditions under which the pests are kept. All pests kept under this permit shall be destroyed at the completion of the intended use, and not later than the expiration date, unless an extension is granted by the issuing office. All necessary precautions must be taken to prevent escape of pests. In the event of an escape, notify this office.

If you have any questions, need additional assistance in the completion of this application, or require information regarding the specific Rules listed, including a list of those organisms that are exempted from this Permit, please contact: Indiana Department of Natural Resources Division of Entomology & Plant Pathology 402 West Washington Street, Room W-290 Indianapolis, Indiana 46204-2739 Telephone: (317) 232-4120 Fax Number: (317) 232-2649 Web Site: www.IN.gov/dnr/entomolo