APHIS 7041 Live Dog Import Health and Rabies Certificate

Clear Form
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.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
ANIMAL CARE

OMB APPROVED
0579-0036
EXP: XX/XXXX

LIVE DOG IMPORT
HEALTH AND RABIES CERTIFICATE
(ONLY REQUIRED TO IMPORT A DOG FOR RESALE OR ADOPTION)

NAME OF THE PERSON INTENDING TO IMPORT THE DOG INTO THE CONTINENTAL UNITED STATES OR HAWAII:

ADDRESS:

CITY:

STATE:

PHONE NUMBER (including country code):

EMAIL ADDRESS (if applicable):

ZIP CODE:

IDENTIFICATION OF DOG
BREED

SEX

AGE
(Year/Month)

COLOR

OTHER IDENTIFYING INFORMATION
(e.g., markings, microchip number, tattoo, tag number, name)

IS THIS DOG AT LEAST
6 MONTHS OF AGE?
(Yes or No)

VACCINATION INFORMATION - GENERAL
PRODUCT NAME

MANUFACTURER

LOT NUMBER AND LOT
EXPIRATION DATE

DATE OF VACCINATION

DATE OF EXPIRATION
OF VACCINATION

VACCINATION INFORMATION – RABIES
DATE OF VACCINATION
PRODUCT NAME

MANUFACTURER

LOT NUMBER

(if initial vaccine, must be
given 30 days prior to entry
in the U.S.)

DATE OF EXPIRATION
OF VACCINATION

Veterinary Certificate
1.

I certify that the dog identified above was examined by me on this date and that the information on this form is true and correct.

2.

I certify that I hold a valid license to practice veterinary medicine in the country of export

3.

The dog was vaccinated, not more than 12 months before the date of arrival at the United States port, for rabies, distemper, hepatitis,
leptospirosis, parvovirus, and parainfluenza viruses 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.

4.

The dog listed above appears to be healthy upon examination and free of infectious disease or internal or external parasites (i.e., free
of any infectious disease or physical abnormality which would endanger the dog or other animals or endanger public health).
I certify that all information provided on this form is true and accurate.

VETERINARIAN'S SIGNATURE:

PRINTED NAME:

ADDRESS OF VETERINARIAN:

LICENSE NUMBER OF THE VETERINARIAN ISSUING THE CERTIFICATE:

APHIS FORM 7041
OCT 2018

DATE: