Aphis 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 numbers for this information collection are 0579-0036 and 0579-0278. 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 U.S.C. 21.43.9; CFR, Subchapter A, Part 2).

OMB APPROVED 0579-0036 0579-0278 EXP XX/XXXX

UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE UNITED STATES INTERSTATE AND INTERNATIONAL CERTIFICATE OF 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 or imprisonment of not more than 5 years or both (18 U.S.C. 1001).

1. type of animal shipped Dog Cat Other Nonhuman Primate Birds Rodents

2. CertificaTE number

3. total number of animals

4. page

5. Name, Address, and telephone number of owner (consignor) USDA License/or Registration Number if applicable Telephone

6. Name, Address, and telephone number of RECIPIENT AT DESTINATION (consignee) USDA License/or Registration Number if applicable Telephone

7. Animal identification

8. vaccination history (Coverage of vaccine)

NAME, MICROCHIP, AND/OR TATTOO NUMBER OR OTHER IDENTIFICATION

Breed – Common Or Scientific Name

AGE

SEX

Color or Distinctive marks

Rabies 1 YEAR 2 YEARS 3 YEARS

Other vaccinations treatment AND/OR TESTS AND RESULTS

Vaccination Date

Product

Date

Product Type and/or Results

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

REMARKS OR ADDITIONAL CERTIFICATION STATEMENS (When required)

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.

I certify that I have verified the identity of the animals listed in box 8.

I certify that the animal(s) described and on continuation sheet(s), if applicable, have been inspected by me on 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 the animal or other animals or would endanger public health.

Signature

Date

To my knowledge, the animal(s) 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 (NOTE: International shipments may require certification by an accredited veterinarian. States may also require such certification.)

Name, Address, and telephone Number OF VETERINARIAN

License number

Apply USDA Seal or Stamp here

Accredited Yes No

Licensing State

Signature of USDA veterinarian

Date

SIGNATURE

DATE

APHIS Form 7001

(SEPT 2009) This certificate is valid for 30 days after issuance