7001 United States Interstate and International Certificate o

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0579-0036. The time required to complete this information collection is estimated to average .25 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

No dog, cat, nonhuman primate, or additional kinds or classes of animals designated by USDA regulation shall be delivered to any intermediate handler or carrier for transportation in commerce, unless accompanied by a health certificate executed and issued by a licensed veterinarian (7 USC 21.43.9 CFR, Subchapter A, Part 2).

OMB APPROVED 0579-0036 Exp. XX/XXXX

U.S. DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE UNITED STATES INTERSTATE AND INTERNATIONAL CERTIFICATEOF HEALTH EXAMINATION FOR SMALL ANIMALS

Warning: Anyone who makes a false, fictitious, or fraudulent statement on this document, or uses such document knowing it to be false, fictitious or fraudulent may be subject to a fine of not more than $10,000 0r imprisonment of not more than 5 years or both (18 U.S.C 1001).

1. type of animal shipped Dog Cat Other Nonhuman Primate

Certification number

2. total number of animals

page

3. Name, Address and telephone number of owner/consignor USDA License or Registration Number If Applicable Telephone

4. Name, Address and telephone number of consignee USDA License or Registration Number If Applicable Telephone

5. Animal identification (To be completes by owner/consignor)

6. vaccination history (To be completed by Veterinarian)

a ttach original signature Rabies certificate here

Complete USDA Tag Collar and/or Tattoo Number

Breed – Common Or Scientific Name

AGE

SEX

Color or Distinctive marks

Rabies Killed Virus Live Virus

D-H-L

Other vaccinations Tests or treatment

Date

Product

Date

Product

Date

Type/Result

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

“x” Applicable Statement

Veterinary certification: I certify that the animals described in item 5 have been examined by me this date, that the information provided in item 6 is true and accurate to the best of my knowledge, and that the following findings have been made “X” applicable statements.

Owner/consignor certification: I certify that the information concerning the animals described above in item 5 is true and that I am the owner/consignor of such described animals and that I have physical and legal custody of such animal(s).

I certify that the animals described and continuation sheet(s) if applicable, have been inspected by me this date and appear to be free of any infectious or contagious diseases and to the best of my knowledge exposure thereto, which would endanger

I hereby certify that the animal(s) in this shipment is (are), to the best of my knowledge acclimated to air temperatures lower than 7.2ºC (45ºF).

I certify that the animals described above, and on continuation sheet(s) if applicable have been inspected by me this date and appear to be free of physical abnormalities which would endanger the animal.

Signature

Date

To my knowledge the animals described above and on continuation sheet(s) If applicable originated from an area not quarantined for rabies and have not been exposed to rabies.

Endorsement for international export (warning: International shipments require Certification by an accredited veterinarian. States may also require such certification).

Name, Address and telephone Number Telephone

License number

Apply USDA Seal or Stamp here

Accredited Yes No

Licensing State

Signature of USDA veterinaian

Date

Signature

Date

APHIS Form 7001 This certificate is valid for 30 days after issuance

JUN 2009