The fourth page of the form has an additional declaration:
This office has on file a notarized affidavit from [company name] verifying the accuracy of the statements below:
The inedible non-ruminant byproduct certified hereon:
The fourth page of the form shows a stamp of the United States Department of Agriculture and has a number of fields that require filling in.
The product field says: inedible non-ruminant byproduct (intended for pharmaceutical use) **Include name/establishment number of Food Safety and Inspection Service facilities product is obtained from.