EVANZ KENNEL PERMIT (K19-000040).PDF

Maricopa County
Animal Care and Control
2500 South 27th Avenue
Phoenix, AZ 85009
(602) 506-7387 Tele.
(602) 506-2739 Fax
KENNEL PERMIT
APPLICATION K19- 0000LIO
0 New El/Renewal
Name: Kennel Name: VA - IV
Mailing Address: 6.6/5,5 IV 3tr-142)1/6- Kennel Address: ....SOL4'3')-e--
City: Ph (y42..e'/_.:,State: AZ Zip: ( .4.-6_5:3 City: Zip:
County Supervisorial District: 3
Phone: 6 - 0:2 Kennel Phone: 5e2/72-1.-C.
Please complete and sign this application and return it to the above address with payment in the amount of three
hundred fifty dollars ($350.00) within ten (10) days of receipt.
NOTE: Failure to renew the kennel permit by the expiration date of the previous year kennel permit will result in
penalty fees for each dog being assessed at $6 per month for unaltered dog and $3 per month for altered dog in
addition to the permit fee. It is suggested the renewal application be submitted 4 — 6 weeks in advance of the
expiration date to allow timely processing.
Pursuant to Arizona statute and county ordinance, a person must obtain a kennel permit issued by the Board
of Supervisors if the person operates a kennel in which there are five or more dogs which are not individually
licensed. A.R.S. §11-1009(A). A kennel is defined as "an enclosed, controlled area, inaccessible to other
animals, in which a person keeps, harbors or maintains five or more dogs under controlled conditions."
§ 11-1001(8).
An appointment will be scheduled for inspection of the kennel _premises by an Animal Control Officer upon
receipt of this kennel permit application and fee. This kennel application properly executed and a copy of the
inspection report will then be forwarded to, and must be approved by, the Maricopa County Board of
Supervisors. The kennel permit form will be sent to you after approval and will be valid for one year from the
date of the Board's approval.
NOTE: Failure to show for a scheduled inspection and/or failure of inspection will warrant a Subsequent
Inspection Return fee of $49 for egch additional visit at time of inspection. Failure of inspection may result in
denial of the kennel permit and require individual licensing of each dog under the provisions of A.R.S. §11-
1008.
PLEASE ANSWER THE FOLLOWING QUESTIONS AND INITIAL EACH RESPONSE
1. VAT I/We assume complete responsibility for the kennel at the premises for which I/we are making
plication for a permit and understand that "kennel" means an enclosed, controlled area, inaccessible to

other animals, in which a person keeps, harbors or maintains five or more dogs under controlled
conditions (ARS 11-1001).
2. higVe certify that I/We have 4/6 dogs and that the kennel meets the definition in statute.
3. yeINVe certify that I/We have not been convicted of a violation of A.R.S. §§ 13-2910 (cruelty to animals)
or y3-2910.01 (dog fighting), or similar violations of any other state, county or municipal animal welfare law.
(Violations of license and leash laws DO NOT apply).
4. VerINVe certify that all dogs over the age of three (3) months that are kept, harbored or maintained on the
pr9rfiises of the above named kennel have been properly vaccinated against rabies by a veterinarian licensed to
prActice in the state of Arizona and that a current vaccination certificate signed by a licensed veterinarian is
maintained on the premises for each dog.
5. jl /We certify that INVe are submitting a valid copy of the rabies vaccination certificate for each
do witlf this application.
e understand that a dog remaining within the kennel is not required to be licensed individually under
A. S. § 11-1008. I/we also understand that a dog leaving the controlled kennel conditions shall be licensed
un er A.R.S. § 11-1008 except if the dog is only being transported to another kennel which has a permit issued
under this section.
7. , 1,V11/VVe understand that a person who fails to obtain a kennel permit under A.R.S.§11-1009 is subject to a
penalty of twenty-five dollars in addition to the annual fee.
8. e understand that a person who knowingly fails to obtain a kennel permit within thirty days after
wn n notification from the county enforcement agent is guilty of a class 2 misdemeanor..
he undersigned understand that that the kennel permit does not authorize the operation of any type
f Asiness and is solely used for the purpose of licensing multiple dogs.
IniVe certify that all of the information I/We have provided is true and accurate under penalty of law.
79
Applicant Signature 21.LA9/11 Date:
Applicant Signature Date:
For Official Use Only:
Copies of Valid Rabies Vaccination Certificates for each dog attached
Copy of Person's Valid Identification Attached
Type of Identification submitted
BOS Approval Date Term of Permit
October 2015

Maricopa County Animal Care and Control
2500 S. 27th Avenue
Phoenix, AZ 85009-6797
(602) 506-7387
http://oets.maricopaqcv
Receipt Number: R18-634636 Receipt Date: 11/2712018
Person ID: P0999788
Phone: 602 8430219
EVANZ KENNELS 11/27/2018 11:09:30AP
16853 N 39TH DR
PHOENIX, AZ 85053
Item: Animal ID: Reference No: Price: Each: Amount:
KEN PERMIT A7777777 K19-000040 $350.00 1 $350.00
Total Fees Due: $350.00
Payments: Cash:
Check: $350.00
Credit Card:
Total Payments Received: $350,00
Thank You!
Would you like to share your experience with our service to you? Change: $0.00
Please visit our website at http://pets.maricopa.gov and click on Balance Due: $0.00
• "Contact Us" to email your comments for our review.
Animal Information:
A7777777 KENNEL PERM - BORN 9/1411999, SPAYED, UNKNOWN/MIX, TRICOLOR DOG
License information:
Tag Number: License Expires: Animal# Vacc Date: Vacc Expires:
Please retain this receipt with your pet's records
aguayot WBUSOFF

Maricopa County
Animal Care & Control
2500 South 27th Avenue
Phoenix, AZ 85009
Phone: (602) 506-7387
pets.maricopa.gov
KENNEL PERMIT K19-00040
PREMISE INSPECTION
Number of Dogs: 42
Name: Marilyn Pauley Kennel Name: Evanz Kennels
Mailing Address: 16853 N. 39th Dr. Kennel Address: 16853 N. 39th Dr.
City: Phoenix State: AZ Zip: 85053 City: Phoenix Zip: 85053
County Supervisorial District: 3
Phone: 602-843-0219 Kennel Phone: 602-843-0219
1. Are all dogs over the age of three months properly vaccinated for rabies and in
possession of a valid rabies vaccination certificate?
YES
2. Is the kennel an enclosed, controlled area, inaccessible to other animals, in which a
person keeps, harbors or maintains five or more dogs under controlled conditions?
YES
NOTE: Copies of each rabies vaccination certificate must be attached to the Kennel Permit
Premise Inspection form.
CORRECTIVE ACTION NEEDED FOR COMPLIANCE AND N/A DAYS GIVEN
BEFORE REINSPECT1ON. (Note: There will be $49 re-inspect fee payable to the
Inspector by check upon each return visit.)
None. On November 29, 2018 I inspected Evanz Kennels and matched all 42 dogs on the
property with current rabies certificates. The property is enclosed and secure.
Deputy Enforcement Agent & Badge #: Lt. Amber Romero Date: 11/29/18
October 2015

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Print ilt- mo ol 1 i Lic./ irrri-gA lot) Print Ai mo older-V. (First lot)
/21J--'11'e -2
ri2 12 or Age yr. yr. Serial 12 Age yr. yr. Serial
to mo 1 3 to moor 1
RABIES -( mo Actual Producer: Di .1,411-I Vacc. RABIES an mo Actual u Prodcer: CI Vacc.
ith Age: 3 12 ),- Age: 3 12
Address Of -0 .1 17 0 Address , ti'9 pi l'ill 0
EXPIRED: EXPIRED: 0
cop' and Female Neutered _47 Year Year COPY and tr Neutered Year Year
rade Sex: Male VACCINATED: _•S Sex: Male Female VACCINATED: _IL/2 A1)
OWNER'S .Name 'ivist /cry 0 • 111 Day Day Name ' /61,u- Day F. Day
- -1. VACCINATION OWNER'S - s'IF 0 E VACCINATION
Owner's PRiNT Species Dog Other: (specify) DATE Jo Month. Month . .. Owner'i PRINT . Species: Other: Specify) DATE _112 Month 12. Month
No. Cat Dog Cat
OVVNEFI' s COPY RABIES VACCINATION CERTIFICATE Rabies Tag Number
NASPHV Form #51
, Owner's Nartie and Address Print - use ball point pen or type (Tr D-0 i
-0
-0 xi z -1 ,- *6 1 „
!b. 0 C,
..., "-N, . , iNcli
Sex: Age: Size:
Male El 3 no to 12 mo 1:1 U nder 20 lbs4-
Female -•44 12 mo or oider 20 - 50 lbs. 0
N eutered 0 Ar:h 'al Ann r Over 50 lbs. El Name ,'-
Artu511 Ibs .
!
›•
F. RI < 0 _p_ > -o a a c
8- I 'zip st 3 letters) — i
a .- ,‹ 0 Vacc. (SIgnailire) . r E /5---74-41 , 5 ,K ,
Address ,,..)
liE Vacc,
o *0 E o m o -' 3ther 1120-r.4)
5,4
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4. 0 E ..‹ a) o o M
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Number 1.c• Number ---0:L-P71
,,,_.- Zip,,i% Colors: I* Zip Colors: Dr--
S-A. 41 4 ' Tag
Tag -13)---0 e)-1.-_,.. frkih A.,,,,iir
,r1 c- 6(5- if Telephone .1 -
Rabies Telephone - No.) OTi-YV)---.4:-Lkit-4 151y7( Rabies 4,11—z-H-J3 -.' ____1_,,_. Net 4
-.,—'S.'-' -2- i-rcya te '...,- .
rte "L'' ../ (License - , 4 g iL:conse ,...._, _
.L 6 L., ilTh4(14410 17: I M.!. Breed: / .4....
.6" Breed: Ui" i 4' .....---
je # 3)__g -
CERTIFICATE i v., --.7 Z
CERTIFICATE et0-1) 4 a / / Predominaht Veterinarian's:
type Predominant Giree Veterinarian's: "7 Address: 7a type Name'- (Signature) Address: .
...1.... Name: (Signature) or ,
or #57 „
#51 pen 1: pen IE E lbs
lb-r-fAi-
Form lb . Form point city/ lbs. lbs.
point lbs. r Ibs. 20 7
City 20 Actual_lbs First 50 60
ball First 50 50 VACCINATION NASPHV WI Under - Actuai H-E
VACCINATION NASPI-11/ Size: Under - Over -E Size: 20 Over letters)
use 20 letters) use 0•
- itgrio. 2 Other no. - El 3 Lic./Vacc. Lic./Vacc. Other
,,i El {First Lic./Vacc. LiciVacc. Print (F:rst
Print mo oldel•51, 2_. 3D-0( (lot) mo cider
ES r 12 Age yr. yr. Serial /;?/7,,,, to 12 or Age yr. yr.
4...?c7ii to or 1 )-9 RABIES iku- mo Producer: 1 X3
RAB 1114 mo no Actual Producer: 0 14.3 7,/, Age: mo 12 Actual • 0
Age: 12 Vacc. 3
3
Address E El
Address E
EXPIRED:
i EXPIRED: az and Neutered 7 Year
COPY and Female Neutered Neutered 1 Year Year Sex: Maie Female /
134i,d Sex: Male VACCINATED: . '3* Name ,rt. VACCINATED: a
OWNER'S Name Last / 3 Day Day - -7A E E /IF Day ACCINATION
- "gi E E J VACCINATION
iwner's PINT pecies: og 'then pecIfy) ATE 110 lonth io
Owner's PRINT Species: Other: (Specify) Month 17 Month at
No. Dog Cat DAT li
•
OWNER' S COPY RABIES VACCINATION CERTI FICATE
NASPHV Form #51 Rabies Tag N umber
I
Owner's Narne and Address Print - use ball point pen or type
Tist.7 First M .I . I Telephone •
7,14 'Lk.) d
,
....
Sex: Age: Size:
Male 3 mote 12 mo LJ Under 20 lbs.
Female Lii 12 me or older 20 - 50 lbs. D
Neutered 0 Actual Age4r- Over 50 lbs. 0 -
Actual _C_ lbs. Name:i
o M < > ci-) „..., ). , 2 > —I m g tn
1\3 0
C '"-- ....) st 3 letters)
K =( gt Ci iiit ti< El Vacc . (SIgrreture) )s-././
Address:12s
Vacc .
< C) 2 > 0 z rn X 55 rn 0 .. Other
7.6k7oe, A:1-rs:m
a ......„..
Tirt,
ci :•< x Vac . Serial-(ldt) no.

'
Number Number
2)3-02-)9 iveW -....-, i .7—iP Colors:
Tag _ A3 ...."- Tag --a-Li /fell
Rabies Telephone No.) 1.145---2-/ ephone
Rabies ) 91 ') ....L--.0 0 N1 A,_._,
(License 2P Ts — StatE76-_ 1 Licensa)
7; rr
M.I. # M.I. ():===.-- A Sreed: ....,--,/2: ,.... (
ur- .,, # s: _
CERTIFICAT Veterinarian's: CERTIFICATE ..1: /
type type Predominant , Veterinarian' ,,„04
or Name: (Signature) Address:
#51 pen CI CI #51 or
lbs pen CI E lbs.
Form point lb 20 lbs. lbs. Form point lbs. lbs.
ball First 50 50 Actual First City 20 lbs. 50 50
VACCINATION NASPHV Size: Under - 20 Over letters) VACCINATION NASPHV ball Size: Under - Over Actual
use 3 no. -'use 20 letters)
- (First Lic./Vacc. Lic./Vacc. Other (lot) 1:1 3 Uc./Vacc. Lic./Vacc. Other no.
Print mO old Print ll'ute mo Agej.n 3 (First (lot)
12 Age yr. yr. Serial )//i1.) 1 olde
RABIES to moor Producer: 4 3 0 / / 1 12 to or 1 yr. yr. Serial
Age: ma 3 12 Actual Vacc. RABIES "v5) ma mo Actual Producer 111 Tef-3 Vacc.
Age: 3 12
Address CI El 9 0
EXPIRED: Address g:Yi ,../
COPY and Eg_. Male Female Neutered Year 11,4 Year COPY and -t Neutered Year EXPIRED: ,e` Year
Sex: VACCINATED: Str- Sex: Male Female 3AI c
OWNER'S Name CI 13 Day )3 Day Name Last VACCINATED: )3
PRINTifast VACCINATION OWNER'S - El i Day Day
Owner's No Species: Dog Cat Other: (Spedify) DATE ii Month ti Month Owner's PRINT Species: Other: (Specify) Month VACCINATION )) Month
No. Dog Cat DATE

Cat Dog No. Month p Month I/ DATE (Specify) Other: Cat Dog Species:, No. PRINT Owner's
Month Month ii DATE (Specify) Other Species: PRINT Owner's VACCINATION • -
),•)3 VACCINATION , 0 E )6747-05 - L Day /3 Day 13 D 0 "" 41.1, Name OWNER'S
Day Day /3 It Name OWNER'S VACCINATED: Female Male Sex: r St st /
VACCINATED: Female Male Sex: 3 —Str Year ,5,/ Year i , Neutered L-Ey and CORY
Year ;2) Year ,/,7- Neutered 4 and COPY EXPIRED; , ee/
EXPIRED: V C: 0 IV- Address
0 0 y__4. Cir Address 12 3 Age:
12 3 Age: ' . Vacc. E Producer Actual mo mo -r RABIES
Vacc. 4 E Producer: Actual mo mo 71i RABIES 3 1 Age or to qth )Z
3 1 or to /Van/yid Serial -02- yr. yr. • a 12 y
Serial ,,?_3) yr. yr. Agej 12 (lot) 7,-- (t er mo if Print
(lot) older mo Print 93/J-‘ Lic./Vacc. Lic./Vacc. (First 0 -
Lic./Vacc. Lic./Vacc. (First 'Li 0 _ - no. Other 3 20 ix, use
no. -IC Other 3 use • letters) Actual Over Under Size: NASPHV VACCINATION
letters) Actual Over 20 - Under Size: NASPHV VACCINATION -e 50 -50 First ball
50 50 City First ball 9 lbs. lbs. 20 City point Form
lbs. lbs. 20 point Form lbs. lbs.
Li 0 pen #51
lbs. 0 0 lbs..* pen #51 or
or Address: (Signature) Name' "1-'1' pAo type
Address: (Sk2nature) Name: , ..-- type /2 Veterinarian's: ,i11/1 .5 Predominant CERTIFICATE
Veterinarian's: cy Predominant , CERTIFICATE 7 ••• (.--- 7 c; etAi9
1-7 ) 30)...3— # 0 y
3c).....5-- 7 # 4, ‘6 %.'dij: 204/ s I Breed: M.I.
.17-10ey 60771 "irvyile Breed: M.I.
7 E6 (License A ie it.
E. (LIcense Its 1 ‘ Telephone Rabies
4 No.) ),e, tj Rabies ) 7i
s3 /4-y3—Call Telephone ...o-/)ye,-. s-) , Tag
)s—tx aiir Tag .2"-Pp- z
,-,-i--(w) if/ItT Colors: Zip ry) vey Ccjors: Number
ip-.., Co ./ Number
/ _4_ I
".

•
Number 7 ) Number -,-P '"-- 1"
0;0 zir Colors: Colors: 1--/ii ) g
Tag Tag LC t i ''''
Telephone • ( Tele.phone A v 2-
Rabies No,) .Rabies )5-
te - ' e j Na.) -,
(License S r)d , )4- E
M.I. Breed: : /1;trIAZ MI 16(6 , Breed: -
,rt 3,2s- e-?,(.1 ,I
£ (ri /4J L - —1 eil---
fl Noe,J Predominant Veterinarian's: (2.4 CERTIFICATE Predominant ..-- C91 1 Veterinarian's: Veterinarian' ure)' ) al _
1 type Name: (Signature) Address: type Jo i Name: Address:
or or (License (Sig
#51 pen lbs.-4 El El #5/ pen CI CI lbs
lbs. lbs-4
II % Forrn point 20 lbs. lbs. / Form point lbs. i s.
`IB.17,, ball First City 50 50 First City 20 50
NASPHV Size: Under - Over Actual VACCINATION NASPHV ball Size: Under -50 Over Actual C
% use 20 letters) use 20 letters)
r0 - ,„he E 15f. Yr 3 Lic./Vacc. Lic./Vacc. no. - 0 (First) LiciVacc. Lic./Vacc. Other no.
Print ma (First Other (lot) Print Ly4/1 mo older-y, (lot)
4 oider ) 12
4/3,1,94.„ 12 Age yr. yr: Serial N'i or Age yr. yr. Serial
eAr—miu,1 mo to moor Producer: 1:171 lirg. 3 RABIES /nap) mo to mo Producer: E 1 15;En
Age: 3 12 Actual Vacc. Age: 3 12 Actual Vacc.
z
Address El Et Address E 54 El
tu_i_zy. EXPIRED: 4,44,1,-A4 eetki.... EXPIRED:
and r...-Street Female Neutered is; Year ;-) Year COPY and Male• Female Neutered /o? Year 01) Year
Name et Sex: Male VACCINATED: Name Sex: VACCINATED:
- . 6. El E 13 Day )3 Day OWNER'S -Last do 1E1 E /3 Day •13 Day
VACCINATION , / VACCINATION
Owner's PRINT No. Species. Dog Cat Other: (Specify) DATE JL Month )) Month Owner's -PRINT No. Species: Dog Cat Other: (Specify) DATE 1) Month ii Month
S,E9N100 Ad00
Cr. (.0 5
Ce
t7:r in
n
ivci :0J1VNIOOVA uepeupol :s, #
c,
CD
NOILVNIOOVA 1dX] :028
0 co

,
Number r.7:: -,
Zip Colors. _V_ j Number
Tag - af,40-12i-16 M7tc; 7,/ r 1., Colors: 1:Vitt,i=r1 iiiI
• /-
es Telephone jag (.?
Rab ate a-s. ) No.) i /..; Rabies Telephone No.)
, i-k---- A (License F..,,, 14
..,_ S,Iate P'-''' l_lcense -A-,,,,-(-7.; E-,
M.1. /02—F-1/ Breed: (Y-7/ # 5 r- -
FICATE -' t'ii M.I. - • Breed: 4
I "). L.) 60 . f 1 4,
type X Predominant 4 Veterinarian's: CERTIFICATE Veterinarian's:
CERT Name: (Signgure) Address: type Predominant —C's Name: (Signature) Address:
or 1
#51 pen , E E or p .
lbs.tigl'- Ibs. #51 pen i _ n ,..... E lbs.
Form point lbs. lbs. lbs.
First City 20 50 Form point lbs. lbs. /I
VACCINATION NASPHV ball Under 50 - Actual C First City 20 50 50 E
use Size: 20 Over fetters) VACCINATION NASPHV ball Size: Under - Over Actual letters)
- I D 3 Lic./Vacc. Lic./Vacc. Other no. use „, 20 0 3 no.
Print 1 mold older 2_ {First (lot) - 0,-„, . moA•I El 64213 {First Lic./Vacc. Lic./Vacc. (lot)
12 Print ‘,T1 older
i to or Age 1 yr. a yr. Serial 12 Age yr. yr. Serial
RABIES 1nak'j Age: mo mo Actual Producer: . - E Vacc. RABIES the-re/. lt/ to or mo Producer: _t)Tri El 3
' 3 12 Age: mo 12 Actual Vacc.
Address 4 E 2R. El 1 Li 3
--*" EXPIRED: Address E
COPY and P4U-Le-y, Street' Female Neutered _a_ Year / Year ey treet/..) 1:5' Year EXPIRED: Year
Sex: Male VACCINATED: COPY and Last7 Male Female Neutered
OWNER'S Name Last e- _ta" E E A Day ),3 Day Name Ati..41 Sex: VACCINATEa 13 Day
- VACCINATION OWNER'S - 1.1 0 E Day VACCINATION
Owner's PRINT No. Species: Dog Cat Other: (Specify) DATE 41 Month 11 Month Owner's PRINT Species:, . Other: (Specify) DATE ) ) Month Month
No. Dog Cat

91-N2 -1 q 0
• Washington OFF C AL $IVIALL ANIrvIAL FIEALTH CERTIFICATE . L
Snit Dq•ailni.-Nit of (covering canine, feline and other small animals only) U.S. Department of Agricuitore
WSDA'N Lu-r-e' • 'APHIS Veterinary Services
Animal Services Division SSIIIIPPfv1ENT IS FOR: a...INTERSTATE 1:1 EXHIBITION INTERNATIONAL 1550 Irving St. SW, Suite 100 •
PO Brix 42577 • Olympia W49,9-504,1577 Tumwater WA 98512-6368
(360)902-i878 . - :2. - 2 bi"::". 2 - ö-" • (360)753-9430
RAVELING / OR SHiPPED FROM VIA TRAVELING OR SHIPPED TO
NAM NAME I\ k
:) ' f . \C \ I \ -1\(,)-X- ;\ C .
STREET AUTO STREET .._.)
5( 0 1 E TCI-K-
ErTY STATE 91,Y..„. STATE Tri,
UC) Pt \SW 1
.{* To the best of my knowledge, the animal(s)in this shipment is (ore)acclimated to air temperatures lower than 50°F but not lower than a minimum temperature of :•(:) °F.
I hereby certify that I have examined the below described animal(s) and fincl same to be free from symptoms of communicable disease, and to the
best of my knowledge have not been exposed to rabies or other communicable diseases and did not originate within a rabies quarantined area.
DESCRIPTION RABIES IMMUNIZATION DATA
SPEOES BREED . SEX AGE COLOR OR MARK iNGS VACCINE TYPE rvIG. & SE R iAl. NO TAG NO, OATE OF VACC.
-tOLk ••--,\ , - ..:.. ia 27-
?c_cc7.-'ilQ IT— 3 L)\..Q / k - , \-e_.-1 i i -1 1 .,..7, 7 /.; i I L' ri
_ , • i „,.k.‹.,...,_s et/
CLCO 1 c\ t._, , • va (--\ \ - . --,--L..3 13 L\Q„1,... 14 , 0,,,..( , ---,, ,,,,::2„, L4 .2.2 :-.' Li
\ \ \ • .. N N . . N 1
REMARKS: .
Name Veterin of a ri Accrddited an {please ern) CT,...A A c k. ,,,.C 1 .,,p—.- ., k.,....... ----;: t C: .e,,,,__. i.,' .N... ,{A.../ ...
Signature of
ACtredited Veterinarian
n t . : ..— n r`.
OWNER'S COPY RABIES VACCINATION CERTIFICATE
NASPHV Form #51 Rabies Tag Number
Owner's Name and Address Print - use ball point pen or type
PRINT - Larvt i First M.I. Telephone
ittle.\- ar ) i ,>, A.1 Acfoeme o )---f—i• 7 , 3 --oD-J? ists-
No. ,4ree() • City. stiAT.o. 3
/ FS A.A 3 ' 7 1 co0 P)12e
Species: Sex: Age: Size: Predominant Breed: Colors:
Dog -* Male 0 3 ma to 12 mo 0 Under 20 lbs:tig. 45 t-014,}
,sy A0,42
Cat 0 Female Ya 12 mo or older* 20 - 50 lbs. 0
Other: El Neutered 0 Actual Age Over 50 lbs. E] . F'
(specify) Y Actual 7 lbs Name; li
s,
DATE VACCINATED: Producer: ..2.... 0 1-- Veterinarian's: # el1)_. l PF7
(LI eri e NO
1 13 le (First 3 letters)
) a/ .° 6-Y4:::11:1241"
Month Day Year (Sigratute)
0 1 yr. Lic./Vacc. 3.45- E, /5-7-4 . ) sir,
X3 yr. Lic./Vacc. Address:
VACCINATION EXPIRED:
Other
0 /3 42) (4_93Apli
Month Day Year Vacc. Serial (lot) no.