VS Form 17-145 United States Origin Health Certificate for the Export 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 0579-0020. 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.

UNITED STATES DEPARTMENT OF AGRICULTRE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
NAME AND ADDRESS OF CONSIGNOR

OMB Approved
0579-0020
EXP.: XX/XXXX

UNITED STATES ORIGIN HEALTH CERTIFICATE FOR THE EXPORT
OF HORSES FROM THE UNITED STATES TO CANADA
PERMANENT EXPORT
NAME AND ADDRESS OF PLACE OF ORIGIN

TEMPORARY EXPORT (*NOTE BELOW)
NAME AND ADDRESS OF CONSIGNEE

CERTIFICATION STATEMENTS
1. The horse was, to the best of my knowledge and belief of the issuing veterinarian, not exposed to any communicable disease within 60 days preceding the date of
inspection.
2. The horse identified below was inspected within 30 days prior to export and found to be healthy and free from evidence of communicable diseases and exposure
thereto.
Either (check appropriate box)
☐

3. The horse has resided in the United States or Canada since birth.

☐

4. The horse has met all of the import requirements of the United States and has resided in the United States for the past 60 days.

☐

5. The horse has resided in the United States for less than 60 days and is accompanied by a health certificate from each country in which the horse has resided during
the 60 days prior to entry into Canada.
6. The horse was tested negative for equine infectious anemia using the ☐ agar gel immunodiffusion (coggins) test or ☐ ELISA at:

Name of Laboratory

Sample Drawn by Me or (name of accredited veterinarian)

Date Blood Sample Drawn

Laboratory Accession Number

State Accredited In

Health Certificate Number
ISSUING VETERINARIAN

ENDORSING FEDERAL VETERINARIAN

Signature

Signature and Seal

Name (type/print)

Date

Name

Date

Valid only if the USDA Veterinary Seal appears over the signature of the endorsing
Federal Veterinarian and health certificate number.
Ensure that the diagram and written description agree. White markings and whorls must be shown.
** Health Certificate valid for 30 days from the date of issuance

Name

Breed

Age

Color

Sex

WRITTEN DESCRIPTION
LF

LIMBS
RF

LH

RH

HEAD
BODY
ACQUIRED MARKS (scars, tattoos, etc.)

Instructions: Mark the diagram with the exact position of any distinguishing marks, scars, or brands. Brands to be drawn in position. Scars to be marked and indicated with an arrow (->). Stars or
blazes on the face and any other markings to be drawn in on the diagrams showing position shape as accurately as possible. Whorls should be marked with a (X). If no markings – this fact should be
stated.
*NOTE: The original copy of the health certificate must remain with the horse if the horse is being temporarily exported. Any clearance by Customs, such as a stamp, must be affixed on the reverse side of
the original health certificate. Horses temporarily exported to Canada must return within 30 days of the date of issuance of the health certificate. Exhibition horses must return 90 days from entry into
Canada.
**NOTE: The date of issuance must be the date of veterinary inspection.
Exporter must furnish four (4) copies for USDA endorsement. The original and two (2) copies accompany the shipment, the fourth copy is for the Veterinary Services Assistant District Director’s office.

VS FORM 17-145
DEC 2016