OIE and FAO Reference Laboratory 
                                for Avian Influenza and Newcastle Disease
                          APHA (Weybridge), New Haw, Addlestone, Surrey, KT15 3NB, United Kingdom.
                 Telephone: +44 (0)208 225 7671  Facsimile: +44 (0)1932 357856  Website: http://www.gov.uk/apha
                                             Email Address: aiwrl@apha.gov.uk
                                              SUBMISSION FORM
            Submitter’s Name:
                                                                      For APHA use only:
            Submitter’s Address
                                                                      CVO Name, address, phone and
                                                                      fax number:
            Phone Number:
            Fax Number:
            Email Address:
            Sample ID*  Sample       Sample           Species*    Age    Country*         Clinical History 
                        type*        collection date*                    Region/District  (include health and 
                                     (day/month/year)                                     Vaccination status)
            *mandatory fields
             FORM VIR 621 v3 – 05/06/2019                                                      Page 1 of 2
            Sample ID*  Sample       Sample           Species*    Age    Country*         Clinical History 
                        type*        collection date*                    Region/District  (include health and 
                                     (day/month/year)                                     Vaccination status)
            *mandatory fields
            It is an OIE requirement for us as an OIE and FAO Reference Laboratory for Avian Influenza and Newcastle
            Disease to submit sequence data from notifiable AI and ND samples to public databases within three months
            of sample receipt. We will do this automatically for H5, H7 and AAvV-1 (NDV) samples submitted to us
            unless you tick here to agree to submit them yourself within three months. 
            When submitting sequences we would like to acknowledge your laboratory. Please provide
            us with author names of those involved in this submission for acknowledgement.
             FORM VIR 621 v3 – 05/06/2019                                                      Page 2 of 2