CDC 75.37 (f.4.421 Notice to Owners and Importers of Dogs

Department of Health and Human Services
Centers for Disease Control and Prevention (CDC)

NOTICE TO OWNERS AND IMPORTERS OF DOGS
Requirement for Dog Confinement

*Asterisk indicates a required field.

*POINT OF ENTRY (City, State/Territory)

FORM MUST BE COMPLETED FULLY
THIS IS A BINDING AGREEMENT ENTERED INTO WITH CDC

OWNER

*Name:

Office or Mobile Phone #:

*Driver’s License or Passport #:
(State/Territory or Country)

AGENT

*ENTRY DATE (mm/dd/yy)
*Home Phone #:
email:

*Street Address:
*City, State (Territory), Zip Code:

~Name:

Office or Mobile Phone #:

~Driver’s License or Passport #:
(State/Territory or Country)

~Street Address:

~Home Phone #:
email:

~City, State (Territory), Zip Code:

*Confinement location: Check if
same as Owner’s Address _____
DOG(S)

CDC 75.37 (f. 4.421)
OMB # 0920-0134
Expiration date: XX/XX/XXXX

*Street Address:

*Phone #:

*City, State (Territory), Zip Code:

*Age/Birth Date:
*Number from Same Litter (i.e., same mother) in this Shipment: ______
*Breed/Color/Description:
*Sex
#Male_____ #Female_____
^*Country of Origin:
*Airline and Flight Number/Ship Name/Vehicle Tag #:

Microchip or Tattoo #:

Waybill #:

~Agent's information is only required if owner's agent signs this form instead of the owner.
^Country where dog(s) has lived the past six (6) months or since birth.

Above dog(s) is/are admitted to the United States, subject to restrictions of section 71.51 of the Public Health Service Foreign Quarantine
Regulations checked below:
1. _____ Confinement for _____ days, which will complete a 30-day period from the date of initial antirabies vaccination.
2. _____ Confinement until 3 months of age, then initial antirabies vaccination to be followed by confinement for 30 days.
3. _____ Confinement until initial antirabies vaccination at destination (within 10 days of entry into the United States) to be
followed by "confinement" for 30 days.
4. _____ Confinement until booster antirabies vaccination at destination (within 10 days of entry into the United States) provided
that initial rabies vaccination was given at ≥ 3 months of age.
The above restrictions are imposed under section 71.51 Title 42, Code of Federal Regulations, and compliance is necessary before the
animal(s) is released from confinement.
"Confinement” as used above means "restriction of an animal by the owner or his agent to a building or other enclosure in isolation from other animals and
from persons except for contact necessary for its care, or, if it is allowed out of such enclosure, muzzling the animal and keeping it on a leash."
NOTICE TO OWNER or AGENT: Criminal penalties may be imposed for violating regulations enacted under 42 U.S.C. § 264. Under 42 U.S.C. § 271, as
enhanced by 18 U.S.C. §§3559 & 3571, individuals violating a quarantine regulation may be sentenced to one year in jail and/or a maximum fine of
$100,000, if the violation does not result in a death or $250,000, if the violation results in a death. Violations by an organization are punishable by a
maximum fine of up to $200,000 per violation, if the violation does not result in a death, or $500,000 per violation, if the violation results in a death.

Statement to U.S. Government Officer (PLEASE READ):
I certify that I am the owner, or authorized agent of the owner, of the above listed dog(s). I further certify that I acknowledge and will
comply with the confinement restrictions checked above. Also, I will be responsible for complying with any additional public health
measures that may be required by health departments or other authority in the State of destination. I acknowledge and understand
that the dog(s) listed on this form are not transferable to another person or confinement location other than those listed on this form.
Signature of Owner or Agent _________________________________________, Date _________________________
OFFICIAL USE ONLY:

I have verified that this document is legible and complete.

Signature of Government Officer __________________________, Title _________________________, Date ______________
Public reporting burden of this collection of information is estimated to average 10 minutes 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. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-0134.