Consignor/Origin Owner (if different from consignor)Name NameAddress Address Phonenumber Phonenumber

Consignee/Destination Name Address Phonenumber

Animal Name Age Sex M F NeuteredSpecies Breed Weight Color/markings Microchip

Other Information

Rabies—Product NameDate TypeManufacturerSerialNumberTag

Test/Vaccine/otherProductname/typeDate

Test/Vaccine/other Productname/typeDate

Test/Vaccine/other Productname/typeDate

Test/Vaccine/other Productname/typeDate

Test/Vaccine/other Productname/typeDate

Test/Vaccine/other Productname/typeDate

Additional comments/Weather Acclimation Statement

Veterinary Certification Statement IcertifythatIhaveexaminedtheanimaldescribedandtothebestofmyknowledgeandbeliefattesttothestatementsindicated:(Check applicable statements)

Notshowingsignsofinfectious,contagious,and/orcommunicabledisease.Theanimalappearshealthyfortransport.

Veterinarian’sSignaturePrintednameTelephonenumber License&/oraccreditationnumber Licensingstate

Consignor /Owner Certification Statement Consignor/OwnerCertification:IcertifythattheinformationconcerningtheanimaldescribedaboveistrueandcorrectandthatIamtheconsignor/ownerofsuchdescribedanimalandthatIhavephysicalandlegalcustodyofsuchanimal.Tothebestofmyknowledge,theanimalhashadnoknownexposuretocommunicablediseasewithinthelast30days.Theanimalhasnotbittenanyonewithinthelast10days.

Consignor/OwnerSignaturePrintedname

CertificateofVeterinaryInspection