Form CDPH 104 Application for Permit to Import Specified Wild Animals Into California - California

Form CDPH104 or the "Application For Permit To Import Specified Wild Animals Into California" is a form issued by the California Department of Public Health.

The form was last revised in September 1, 2014 and is available for digital filing. Download an up-to-date Form CDPH104 in PDF-format down below or look it up on the California Department of Public Health Forms website.

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CDPH Use Only
Permit No.
APPLICATION FOR PERMIT TO IMPORT SPECIFIED
WILD A NIMALS INTO CALIFORN IA
The CDPH Veterinary Public Health Section (VPHS) will endeavor to process permit applications in as
timely a manner as possible; however, VPHS cannot guarantee that a permit will be issued by a specific
date. Importers should submit permit applications to VPHS as soon as practically possible. The application
form should be submitted to VPHS no less than ten (10) business days and all supplementary documents
no less than five (5) business days preceding the anticipated date of shipment. Please submit all
application documents by email to VetPH@cdph.ca.gov.
1. A permit is requested to import the following specified wild animals, in accordance with the provisions of
§
the California Code of Regulations (CCR), Title 17,
30070 - 30086.
Quantity
Common Name *
Scientific Name
* Mammals of the World. Walker E.P., et. al.; Johns Hopkins Press, Baltimore.
2. Are the above animals considered California Department of Fish and Wildlife (CDFW) Restricted
Species (14 CCR § 671)?
No
Yes
If Yes, please provide the applicable CDFW Permit No(s). and Expiration Date(s)
3. Purpose of importation:
Re-Entry
Research
Zoological Exhibition
Non-Zoo Exhibition
Short-term Exhibition (No Contact)
Short-term Exhibition (Human Contact)
4. Expected point of first arrival in California:
Anticipated arrival date:
_________________
__________________
5. Name of carrier:
Transportation mode:
________________
6. Place where animal(s) will be quarantined:
Name
Address
Telephone
Email Address
Accreditation
AZA
Consignor
AAALAC
(origination)
AZA
Consignee
(destination)
AAALAC
Veterinarian
7. Amount Due:
($10.00 per animal: Send check or money order payable to the California Department
__
of Public Health)
CDPH 104 (09/14)
CDPH Use Only
Permit No.
APPLICATION FOR PERMIT TO IMPORT SPECIFIED
WILD A NIMALS INTO CALIFORN IA
The CDPH Veterinary Public Health Section (VPHS) will endeavor to process permit applications in as
timely a manner as possible; however, VPHS cannot guarantee that a permit will be issued by a specific
date. Importers should submit permit applications to VPHS as soon as practically possible. The application
form should be submitted to VPHS no less than ten (10) business days and all supplementary documents
no less than five (5) business days preceding the anticipated date of shipment. Please submit all
application documents by email to VetPH@cdph.ca.gov.
1. A permit is requested to import the following specified wild animals, in accordance with the provisions of
§
the California Code of Regulations (CCR), Title 17,
30070 - 30086.
Quantity
Common Name *
Scientific Name
* Mammals of the World. Walker E.P., et. al.; Johns Hopkins Press, Baltimore.
2. Are the above animals considered California Department of Fish and Wildlife (CDFW) Restricted
Species (14 CCR § 671)?
No
Yes
If Yes, please provide the applicable CDFW Permit No(s). and Expiration Date(s)
3. Purpose of importation:
Re-Entry
Research
Zoological Exhibition
Non-Zoo Exhibition
Short-term Exhibition (No Contact)
Short-term Exhibition (Human Contact)
4. Expected point of first arrival in California:
Anticipated arrival date:
_________________
__________________
5. Name of carrier:
Transportation mode:
________________
6. Place where animal(s) will be quarantined:
Name
Address
Telephone
Email Address
Accreditation
AZA
Consignor
AAALAC
(origination)
AZA
Consignee
(destination)
AAALAC
Veterinarian
7. Amount Due:
($10.00 per animal: Send check or money order payable to the California Department
__
of Public Health)
CDPH 104 (09/14)
Importer, Owner, or Agent
Name
Full Address
Email
Telephone
Signature
Date
Veterinary Public Health Section, MS 7308, PO Box 997377,
Sacramento, 95899-7377 Phone: 916.552.9740
(09/14)
CDPH 104
Email: VetPH@cdph.ca.gov Fax: 916.552.9725

Download Form CDPH 104 Application for Permit to Import Specified Wild Animals Into California - California

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