Live Dog Import Health and Rabies Certificate

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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

LIVE DOG IMPORT
HEALTH AND RABIES CERTIFICATE

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

ADDRESS:

CITY:

STATE:

PHONE NUMBER (including country code):

EMAIL ADDRESS:

ZIP CODE:

IDENTIFICATION OF DOG
BREED

SEX

DATE OF
BIRTH

(MMM DD, YYYY)

COLOR

OTHER IDENTIFYING INFORMATION

MICROCHIP NUMBER

(e.g., name, markings, tattoo, tag number)

VACCINATION INFORMATION - GENERAL
PRODUCT NAME

MANUFACTURER

LOT NUMBER AND LOT
EXPIRATION DATE

DATE OF VACCINATION
(MMM DD, YYYY)

(MM/DD/YYYY)

DATE OF EXPIRATION
OF VACCINATION
(MMM DD, YYYY)

VACCINATION INFORMATION – RABIES
PRODUCT NAME

1.
2.
3.

MANUFACTURER

LOT NUMBER AND LOT
EXPIRATION DATE
(MM/DD/YYYY)

DATE OF VACCINATION

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

DATE OF EXPIRATION
OF VACCINATION
(MMM DD, YYYY)

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

COUNTRY:

LICENSE NUMBER OF THE VETERINARIAN ISSUING THE CERTIFICATE:

DATE:

THIS SPACE RESERVED

APHIS FORM 7041
NOV 2021

Privacy Act Notice

Authority: The Animal Welfare Act (AWA), 7 U.S.C. 2131 et seq., and the regulations issued thereunder, 9 CFR parts 1 through 4; and the Horse
Protection Act (HPA), 15 U.S.C. 1821 et seq., and the regulations issued thereunder, 9 CFR parts 11 and 12.
Purpose: This system supports APHIS’ administrative activities and enforcement of the AWA and HPA.
Routine Uses:
In addition to those disclosures generally permitted under 5 U.S.C. 552a (b) of the Privacy Act, records maintained in the system may be disclosed
outside USDA as follows:
(1) APHIS may disclose the name, city, State, license or registration type and/or status, or change of a license or registrant to any person pursuant to
9 CFR 2.38(c) and 2.127;
(2) APHIS may disclose annual reports submitted to APHIS by licensees and research facilities to any person pursuant to 9 CFR 2.7 and 2.36;
(3) APHIS may disclose inspection reports and other regulatory correspondence issued to licensees and registrants [from the agency] to any attending
veterinarian in order to carry out duties under the AWA pursuant to 9 CFR 2.33 and 2.40;
(4) APHIS may disclose the name, telephone number and other contact information, location, inspection reports, and regulatory and other
correspondenceof licensees, registrants, permitees, and applicants for the same, to appropriate Federal, foreign, State, local, Tribal, or other public
authority agencies or officials, in order to carry out duties under the AWA or State, local, Tribal or other public authority on the same subject pursuant to
7 U.S.C. 2145(b);
(5) APHIS may disclose inspection reports of licensees and registrants, and permit status, to any pet store or other entity that is required under State,
local,Tribal, or other public authority to verify a licensee, registrant, or permitee’s compliance with the AWA;
(6) APHIS may disclose information to the National Academies of Sciences, Engineering, and Medicine, and any other research institution engaged or
approved by the Department, to the extent APHIS deems the disclosure necessary to complete research and/or compile a report in furtherance of the
Department’s mission;
(7) APHIS may disclose final adjudicatory AWA and HPA decisions or orders by an appropriate authority to any person;
(8) APHIS may disclose to any person the name, city, and State or other information to the extent necessary for proper identification of persons
(referred to as “Designated Qualified Persons” or “DQPs”) that are or have been qualified to detect and diagnose a horse that is sore or otherwise
inspect horses for purposes of enforcing the HPA and of horse industry organizations or associations (referred to as “HIOs”) that have currently or have
had in the past DQP programs certified by the USDA;
(9) APHIS may disclose to any regulated horse owner, HIO, and other entities responsible for licensure or required to verify compliance with the HPA,
HPA inspection findings and regulatory and other correspondence issued to persons or entities regulated under the HPA;
(10) APHIS may disclose to any person the name, city, and State or other information to the extent necessary for proper identification of any person or
entity who has been disqualified, suspended, and/or otherwise prohibited from showing or exhibiting any horse, or judging or managing any horse show,
horse exhibition, horse sale, or horse auction under the HPA and the terms of such action;
(11) APHIS may disclose to any person the name, city, and State or other information to the extent necessary for proper identification of any regulated
individual or entity whose license or permit has been suspended, revoked, expired, terminated, or denied under the AWA and the terms of such action;
(12) APHIS may disclose to appropriate law enforcement agencies, entities, and persons, whether Federal, foreign, State, local, or Tribal, or other
public authority responsible for enforcing, investigating, or prosecuting an alleged violation or a violation of law or charged with enforcing, implementing,
or complying with a statute, rule, regulation, or order issued pursuant thereto, when a record in this system on its face, or in conjunction with other
records, indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether arising by general statute or
particular program statute, or by regulation, rule, or court order issued pursuant thereto, if the information disclosed is relevant to any enforcement,
regulatory, investigative, or prosecutive responsibility of the receiving entity;
(13) APHIS may disclose to the Department of Justice when the agency, or any component thereof, or any employee of the agency in his or her official
capacity, or any employee of the agency in his or her individual capacity where the Department of Justice has agreed to represent the employee, or the
United States, in litigation, where the agency determines that litigation is likely to affect the agency or any of its components, is a party to litigation or has
an interest in such litigation, and the use of such records by the Department of Justice is deemed by the agency to be relevant and necessary to the
litigation; provided, however, that in each case, the agency determines that disclosure of the records to the Department of Justice is a use of the
information contained in the records that is compatible with the purpose for which the records were collected;
(14) APHIS may disclose information in this system of records to a court or adjudicative body in administrative, civil, or criminal proceedings when: (a)
The agency or any component thereof; or (b) any employee of the agency in his or her official capacity; or (c) any employee of the agency in his or her
individual capacity where the agency has agreed to represent the employee; or (d) the United States Government, is a party to litigation or has an
interest in such litigation, and by careful review, the agency determines that the records are to be for a purpose that is compatible with the purpose for
which the agency collected the records;
(15) APHIS may disclose information from this system of records to appropriate agencies, entities, and persons when: (a) USDA suspects or has
confirmed that there has been a breach of the system of records; (b) USDA has determined that as a result of the suspected or confirmed breach there
is a risk of harm to individuals, USDA (including its information systems, programs, and operations), the Federal Government, or national security; and
(c) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with USDA’s efforts to respond to the
suspected or confirmed compromise and prevent, minimize, or remedy such harm;
(16) APHIS may disclose information from this system of records to another Federal agency or Federal entity, when the USDA determines that
information from this system of records is reasonably necessary to assist the recipient agency or entity in (a) responding to a suspected or confirmed
breach or (b) preventing, minimizing, or remedying the risk of harm to individuals, the recipient agency or entity (including its information systems,
programs, and operations), the Federal Government, or national security, resulting from a suspected or confirmed breach;
(17) APHIS may disclose information in this system of records to USDA contractors and other parties engaged to assist in administering the program,
analyzing data, developing information management systems, processing Freedom of Information Act requests, and conducting audits. Such contractors
and other parties will be bound by the nondisclosure provisions of the Privacy Act;
(18) APHIS may disclose information in this system of records to USDA contractors, partner agency employees or contractors, or private industry
employed to identify patterns, trends, or anomalies indicative of fraud, waste, or abuse;
(19) APHIS may disclose information in this system of records to a Congressional office from the record of an individual in response to any inquiry from
that Congressional office made at the written request of the individual to whom the record pertains;
(20) APHIS may disclose information in this system of records to the National Archives and Records Administration or to the General Services
Administration for records management activities conducted under 44 U.S.C. 2904 and 2906; and
(21) APHIS may disclose information in this system of records to the Treasury Department as necessary to carry out any and all functions within their
jurisdiction, including but not limited to, processing payments, fees, collections, penalties, and offsets.
Disclosure: Furnishing this information is voluntary; however, failure to furnish this information may impede your ability to comply with the requirements
of the Animal Welfare Act, regulations, and standards.