APHIS 7041 Health Certificate

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 numbers for these information collections are 0579-XXXX. The time required to complete these information collections 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.		OMB Approved 0579-XXXX
UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE Animal care	Health Certificate
The name and address of the person intending to import the dog(s) into the continental United States or Hawaii
Identity of the dog(s) based on the breed, sex, age, color, markings, and other identifying information
State (as required based on the purpose of your importation) the dog is at least 6 months of age
State (as required based on the purpose of your importation) the dog was vaccinated, not more than 12 months before the date of arrival at the U.S. port, for distemper, hepatitis, leptospirosis, parvovirus, and parainfluenza virus at a frequency that provides continuous protection of the dog from those diseases and is in accordance with currently accepted practices as cited in veterinary medicine reference guides
State the dog is in good health (as required based on the purpose of your importation)
Signature and the license number of the veterinarian issuing the certificate
Date

APHIS Form 7041

SEP 2011