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 0579-0160. The time required to complete this
information collection is estimated to average .5 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
0579-0160
Exp.
Date xx/xxxx
UNITED
STATES DEPARTMENT OF AGRICULTURE
ANIMAL
AND PLANT HEALTH INSPECTION SERVICE
VETERINARY
SERVICES
OWNER/SHIPPER
CERTIFICATE
FITNESS
TO TRAVEL TO A SLAUGHTER FACILITY
(Please
type or print in ink)
TIME
HORSES LOADED ON CONVEYANCE
DATE
CITY
AND STATE WHERE HORSES WERE LOADED ON CONVEYANCE
VEHICLE
LICENSE NUMBER AND DRIVER NAME
NAME
OF AUCTION/MARKET
CONSIGNOR
(OWNER/SHIPPER)
NAME
CONSIGNEE
(RECEIVER/DESTINATION)
NAME
STREET
ADDRESS
STREET
ADDRESS
CITY,
STATE, AND ZIP CODE
CITY,
STATE, AND ZIP CODE
AREA
CODE AND TELEPHONE NUMBER
AREA
CODE AND TELEPHONE NUMBER
CHECK
THE BOX THAT INDICATES THE FOLLOWING IS TRUE FOR ALL THE HORSES
ON THIS CERTIFICATE
Pregnant mares are not likely to foal (give
birth)
during the trip.
Horses are able to bear weight on all 4 limbs.
Foals are older than 6 months of age.
Horses are not blind in both eyes.
Horses are able to walk unassisted.
TAG
PREFIX
TAG
NO.
COLOR
DESCRIPTION
BREED/TYPE
SEX
BRANDS
Tattoos, etc
REMARKS
include existing conditions
Bay
Grey
Blk.
Pinto
Chest-nut
Other
TB
QT
Draft
Pony
Other
Mare
Stall
ion
Geld-
ing
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
HORSES
HAVE HAD ACCESS TO FOOD, WATER, AND REST FOR A MINIMUM OF 6
CONSECUTIVE HOURS IMMEDIATELY BEFORE LOADING INTO CONVEYANCE.
SIGNATURE
CANADIAN
FOOD INSPECTION AGENCY (CFIA)
EST.
DATE
TIME
I
HEREBY AUTHORIZE THE CFIA TO DISCLOSE THIS DOCUMENT AND THE
INFORMATION IN IT AS COMPLETED BY THE CFIA OR DGIF TO THE USDA.
FALSIFICATION OF THIS FORM OR KNOWINGLY USING A FALSIFIED FORM IS
A CRIMINAL OFFENSE AND MAY RESULT IN A FINE OF NOT MORE THAN
$10,000 OR IMPRISONMENT FOR NOT MORE THAN 5 YEARS OR BOTH (16
U.S.C. SECTION 1001).
DIRECCION
GENERAL DE INSPECCION EN FRONTERAS (DGIF)
SIGNATURE
OF OWNER/SHIPPER (I
certify that the information contained in this form is true and
correct to the best of my knowledge.)