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Maricopa County Animal Care and Control 2500 South 27th Avenue Phoenix, AZ 85009 (602) 506-7387 Tele, (602) 506-2739 Fax KENNEL PERMIT K17-000024 APPLICATION El New reRenewal Name: Nancy Chapman Kennel Name: Chapman Kennels Mailing Address: 4201 W Tierra Buena Ln Kennel Address: Same City: Phoenix State: AZ Zip: 85053 City: Phoenix Zip: 85053 County Supervisorial District: #4 Phone: 602-896-4019 Kennel Phone: 602-896-4019 Please complete and sign this application and return it to the above address with payment in the amount of three hundred twenty-eight dollars ($328.00) 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 $4 per month for unaltered dog and $2 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." A.R.S. § 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 each 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 -91 1. IANe assume complete responsibility for the kennel at the premises for which I/we are making application 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). 1/We certify that I/We have /7 dogs and that the kennel meets the definition in statute. 3.77e___1/We certify that 1/We have not been convicted of a violation of A.R.S. §§ 13-2910 (cruelty to animals) or 13-2910.01 (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. l/We certify that all dogs over the age of three (3) months that are kept, harbored or maintained on the premises 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. 5.7— certify that INVe are submitting a valid copy of the rabies vaccination certificate for each dog with this application. 6.:12C INVe understand that a dog remaining within the kennel is not required to be licensed individually under A.R.S. § 11-1008. 1/we also understand that a dog leaving the controlled kennel conditions shall be licensed under A.R.S. § 11-1008 except if the dog is onlybeing transported to another kennel which has a permit issued under this section. l/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. 870C--4/We understand that a person who knowingly fails to obtain a kennel permit within thirty days after written notification from the county enforcement agent is guilty of a class 2 misdemeanor.. 9:7e--Thb undersigned understand that that the kennel permit does not authorize the operation of any type of business and is solely used for the purpose of licensing multiple dogs. I/We certify that all of the information WM have provided is true and accurate under penalty of law. %4w___— Applicant Signature 2 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 & Control 2500 South 27th Avenue Phoenix, AZ 85009 Phone: (602) 506-7387 pets.maricopa.gov KENNEL PERMIT K17-000024 PREMISE INSPECTION Number of Dogs: 17 Name: Nancy Chapman Kennel Name: Chapman Kennels Mailing Address: 4201 W Tierra Buena Kennel Address: Same City: Phoenix State: AZ Zip: 85053 City: Phoenix Zip: 85053 County Supervisorial District: #4 Phone: 602-896-4019 Kennel Phone: 602-896-4019 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 REINSPECTION. (Note: There will be $49 re-inspect fee payable to the Inspector by check upon each return visit.) NONE Deputy Enforcement Agent & Badge #: Lt Timothy Rummel Date: 124116 October 2015 Maricopa County Animal Care and Control 2500 S. 27th Avenue Phoenix, AZ 85009-6797 (602) 506-7387 http://pets.maricopa.qov Receipt Number: R16-286877 Receipt Date: 11/30/2016 Person ID: P1246031 Phone: 602 8964019 CHAPMAN KENNELS 11/30/2016 10:40:17A1 4201 W TIERRA BUENA LN PHOENIX, AZ 85053 Item: Animal ID: Reference No: Price: Each: Amount: KEN PERMIT A7777777 K14-000024 $328.00 1 $328.00 Total Fees Due: $328.00 Payments: Cash: $0.00 Check: $328.00 Credit Card: $0.00 Total Payments Received: $328,00 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 9/14/1999, 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 johnsonk EBUSOFF °INNER'S Copy RABIES VACCINATION CERTIFICATE Owner's Name and Address NASPHV Form #51 Rabies Tag Number Print - use ball point pen or type PRINT - Lask./ First M.I. Telephone AlivZ, No. , S;11(111.6141-- ,-- ki/ L ,e4,4 se &late 4/ OLO i IN4 IternaI tt • ty 0 0 Species : , Sex: Age: Size: Predominant Breed: Colors: Dog la Male 1 3 mo to 12 mc717( Under 20 lbs*.Z.t. i / , Cat 0 Female 12 mo or older 0 20 - 50 lbs. g 1 /1, C-f.0 . Other: LI Neutered 0 Actual Age r Over 50 lbs. 0 isPecifY) J IVO Actual j 0 lbs Name: / DATE VACCINATED: Producer: 2... 0 g Veterinarian's: # A 1) F ....."7 (License No.) I i' (First 3 letters) Month Day Year 046 /Cr/J. CZ:4)6P/ 1 yr. Lic./Vacc. (Signature) 0 3 yr. Lic./Vacc. Address: DI C 4, i Yrit S1-. VACCINATION EXPIRED: Other 1/ r /7 15- vroil Month Day Year Vacc. Serial (lot) no. 0,,,!I:, vs copy RABIES VACCINATION CERTIFICATE NASPHV Form #51 Rabies Tag Number Owner's Name and Address Print - use ball point pen or type PRINT iliist First M.1. Telephone I 7 aviraivi/Vedixr fixo „v_t„,.. red5,3 No. Street , k./ ,__. Cil-A. ',poi wo iler- Buciva Species: Sex: Age: Size: Predominant Breed: Colors: Dog ix' Male 3 mo to 12 mo 0 Under 20 Ibl Cat 0 Female 0 12 mo or older/4 20 - 50 lbs. /&/71.>, C-r Other: MI Neutered 0 Actual Age ri,,,,- Over 50 lbs. 11:1 (specify) i i ActualA*Ibs. Name: r /5 --)6 PYSO ik) DATE VACCINATED: Producer: .2„. En 1:.= Veterinarian's: # (License A No.) ‘•-/ I-- (First 3 letters) 614 7.0-p,a, _i_i__F / 4_ Month Day Year 0 1 yr. Lic./Vacc. (Siatue) gnr Address: it 3..2.S- E e, 116 yr. Lic./Vacc. VACCINATION EXPIRED: Other /1 ps—.4i 70127A, / rai 9 ril Mo 1,- 1 h y Yer ' 7 Vacc. Serial (lot) no. 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 - La t First M.1. Telephone "pi me/42/1 itictileG, COI Pit- i-N,7 No. ttreet ,--"' City A ),. S os-3 Zip' 1-0-0) 1/1fi' i ierr6- elk. jil'r rheP-4 teir Species: Sex: Age: Size: Predom'rfant Breed: Colors: Dog '14 Male 0 3 mo to 12 mo D Under 20 lbsr-1/1 e- 4 eij•-c-,71h.Xit Cat LI Female 12 mo or older-f±e.1 20 - 50 lbs. 0 a i /211 Other: 0 Neutered Actual Age Or Over 50/ 11: }br El (Specify) Actual ifi lbs. Name: 1 ./.. DATE VACCINATED: Producer: 2._ a e Veterinarian's: # 2---/ i rcense No) _a iS (First 3 letters) OA /, /1 aid/ 10 Month Day Year 01 yr. Lic./Vacc. (Signature) 3L s-i-, Address: „ If ii ti4 3 yr. LicJVacc. VACCINATION EXPIRED: Other 4F — ) /e--170e2, Lo 41— iF 377 st1=8 Month Day Year Vacc. Serial (lot) no. OWNER'S COPY RABIES VACCINATION CERTIFICATE Rabies Tag Number NASPHV Form #51 Owner's Nameand Address Print - use ball p pen or type First t M.I. Telephone PRINT - Last CI Chop &AA/ Ale/N-4/1 l °irk 71 — ii 0/ No. 44.1 opt tis 4-13 .(a440,. Mcd,A,City i-12.76-0 Atate , --$041. Age: Size: Predominant Bieed: C lors: Species: Sex: Male 3 mo to 12 mo CI Under 20 lbs. .- 7-- - Dog .$ Cat 0 Female 12 mo or older 20 - 50 lbs. 0 Other: 0 Neutered Actual Age,2-Yr Over 5 0 Name: a (Specify) Actual . lbs 2._ 0 1-- Veterinarian's: # o- DATE VACCINATED: Producer: C.' (License No.) (First 3 letters) al ,' 2;707 • /I /a- IY (Signature) Month Day Year 0 1 yr. LicJVacc. Address: Eg /5'./.45-7-- .TE6 yr. Lic./Vacc. VACCINATION EXPIRED: Other A)_, "fri--P1 17 3 13 0 zic Month Day Year Vacc. Serial (lot) no. OWNFI l'S COPY RABIES VACCINATION CERTIFICATE NASPHV Form #51 Rabies Tag Number Owner's Name and Address Print - use ball point pen or type PRINT -list First Mi. Telephone chipnvoim Apcy Ko).- 'Tit-L(00 No. 'Street -, City "he ,„ Altatec, (... 0 1101V / i4/.3 r/errC" Bt•KeA IAA i Species: Sex: Age: Size: Predominant Br : Colors: , Dog YL Male 0 3 ma to 12 ma CI Under 20 lbs* I 1 a 131-4/4 /‹./ AiO rh- IP- Cat 0 Female 12 ma or older 20 - 50 lbs. Other: 0 Neutered Actual Age Over 50 lbs. CI (Specify) Actual _albs Name: J alZrA DATE VACCINATED: Producer 7_____ el r- Veterinarian's: II 711" f/el .../ 1-_-, (License No.) .... jeir ___L? p_ lc (First 3 letters) 7G- i r .0, Vig Month Day Year 1:1 1 yr. Lic./Vacc. (Signature) Address: 3t2S E A-V ET-- .p-!0, yr. Lic./Vacc. VACCINATION EXPIRED: Other /e-ock, AL-onaloY) JO a a c / 7 STIR Month Day Year Vacc. Serial (lot) no. OWNER'S GOP' r RABIES VACCINATION CERTIFICATE Rabies Tag Number NASPHV Form #51 Owner's Name and Address Print - use ball point pen or type First M.I. Telephone PRINT -I4t t116qiretip Sta No. reet / City PkemieA iilt)) V.. ie.--"Yr,Vvem-, A-A, J Species: Sex: Age: Size: Predominant Breed: Colors: Dog --)141. Male * 3 mo to 12 mo CI Under 20 lbs* /<-/ i " (1.(1 rk AF-raAivh Cat LI Female LI 12 ma or olderlg 20- 50 lbs. 0 - Other: 11:1 Neutered 1:1 Actual Age Myr Over 50 lbs. 0 Name: / tspecilY1 Actual IF lbs. 7-r-47 DATE VACCINATED: Producer: 7..._., 0 ,..C. Veterinarian's: # (Licen a No.) ad /5 (First 3 letters) 4 - 6)7-0: /0 4s (Signalise) Month Day Year , I=1 , 1 yr. Li c./Vacc. Address: Add 3?-5- ft .. rSr, 114,3 yr. Lic./Vacc. VACCINATION EXPIRED: Other Jo a IF Month Day Year Vacc. Serial (lot) no. 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 - 4,6..y First M.I. Telephone 60:1. 140i 7 t-ACifirACAAJI M No. Stfeet i City A stays_o slip Lilo/ 1„/., ilerra. atteiv, Ptoeme / Species: Sex: Age: Size: Predominant Breed: Colors: Dog X Male lg. 3 mo to 12 mo Under 20 lbs. 0 D k a d pig /Lj tic.,_ Cat 0 Female 12 mo or older 20 - 50 lbs. 14 rt ef a - Other 0 Neutered 0 Actual Age)....yr Over 50 lbs. 0 (Specify) Actual lbs. Name: fli6V- DATE VACCINATED: Producer: 2_ f Veterinarian's: # 2--‘ 11(19 o (License>9.) /0 II_ IS (First 3 letters) tg4 Month Day Year 0 1 pig a mei yr. Lic./Vacc. Address: 3 is- ET, I rti ...NI: yr. Lic./Vacc. VACCINATION EXPIRED: Other iP irvP-, A / 0 I cl IF ./h12S-S a..„8 Month Day Year Vacc. Serial (lot) no. OWNER'S COPY RABIES VACCINATION CERTIFICATE #51 Rabies Tag Number NASPHV Form Owner's Name and Address Print - use ball point pen or type PRINT -Lyst First M.I. Telephone Cha, rr.a.A.) ) 6 No. Street ri-es3 1/10/ W., Terr& 14-6}t/Clh itY iii/C r- A A j tj S 5 - , Species: Sex: Age: Size: Predominant Breed: . Colors: Dog Male 0 3 mo to 12 mo 0 Under 20 lbs)A 16 , Cat Female ....jkf 12 mo or older-4 20 - 50 lbs. 0 ' --j (1"r/el- -"----- Other: C3 Neutered 0 Actual Age Cfyi.- Over 50 lbs. 0 (Specify) Actuallbs. Name: A 1,4e_r_ DATE VACCINATED: Producer: .1. 0 f--- Veterinarian's: # (License M ___a..) I)--_ )5 (First 3 letters) 124-70-rd-i Month Day Year 0 1 yr. Lic./Vacc. (Signature) re 3 a s -E- 'CV 5-1-- Address: ..CK3 yr. Lic./Vacc. ...---- VACCINATION EXPIRED: Other j 0/a, ly 577.5-- 5 Month Day. Yew Vacc. Serial (lot) no. 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; Vast First M.I. Telephone t-haipmaiki Nopcy 7 No. 1/2.,0) smit, hrry,,, ot1 Civ, a, State A yr, P em)*, MI- 0S3 Species_ : 1 Sex: Age: Size: Predominant Breed: Colors: Dog A Male "A 3 mo to 12 mo D Under 20 lbs. 0 w.l_A!„. • C c irle-44/ 1z Cat 0 Female D 12 mo or older 0 20- 50 lbs. D 1 ' 7 ° Other: CI Neutered 0 Actual Age Over 50 lbs. 0 (specify) Actual i__?_lbs. Name: f 1-.14.5.3V Ax.„) i PI DATE VACCINATED: Producer: 2._ Veterinarian's: # 0 E (License No.) I --LL- (First 3 letters) Oa d %Pnos-, Month y Year (Sig ure) El 1 yr. Lic./Vacc. Address: El / 5""t) St,. 10 yr. Lic./Vacc. VACCINATION EXPIRED: Other 7°114/ A if Cl i ) ro1.4 L i 5 A M n h Day Yea Vacc. Serial (lot) no. coiv'NER'S OOP( RABIES VACCINATION CERTIFICATE NASPHV Form #51 Rabies Tag Number Owner's Name and Address Print - use ball point pen or type PRINT- La, st r First M.I. Telephone iy()) , ? No. i , Sfeet ,./2116:Z p t.Ly St . 7;4/ IAA iir. - Me/Lc P/oeii-le 00 Species: Sex: Age: Size: ! Predominant Bra': Colors: Dog X Male 0 3 mo to 12 mo 0 Under 20 lbs15 ii , c 7- zWivri+ Cat 0 Female Nk 12 mo or older- 20 - 50 lbs. 0 Nill 4- ° (---='- Other: 0 Neutered 0 Actual Age Aer Over 50 lbs. 0 (Specify) I . Actual 1,5- lbs Name- • Vetir i n DATE VACCINATED: Producer: 1 0 c Veterinarian 's: # (License P's No.) ''-`.",) Al r A. (First 3 letters ) ate,,.%,„„),, ad Month D y Year El 1 yr. Lic./Vacc. (Sign urer 3)___s- 5. Address: irtatI 3 yr. Lic./Vacc. VACCINATION EXPIRED: Other it k 11 I D-P-iS A Month Day Year Vacc. Serial (lot) no. OWNERS COP.! RABIES VACCINATION Owner's Name and Address NASPHV Form CERTIFICATE PRINT - La, Print - use ball point pen #51 Rabies Tag Number or type First No. v, N fee i tit f. Telephone # °-111r-L-10) i C ity , ( Species: Sex: Dog 74 MaleX Age: Size: PhoitAs,-I).. ifts3 Cat 0 Female 3 ma to 12 mo 0 Under 20 lbs Predominant Breed: Other: 0 Neutered 0 12 mo or older 20- 50 lbs. /44A1 Colors: (SlaccifY) Actual Agek _ C1C- 1' r Over 50 lbs. 0 -7/ -tolcut-- Actual /7 lbs. Name: i .., d ,, DATE VACCINATED: ifridi 0 r Producer: .2._ 0 g g Veterinarian's: # Month Day Year (First 3 fetters) (License 2,./1/r, No. -1 yr. Lic./Vacc. (Signature) 40 7C;rv.(2I-•‘...6, VACCINATION EXPIRED: 3 yr. Lic./Vacc. Address: E. lid ./..,vdil 3.1S- i-7,-, 1/ F 17 Other Month Day Year Vacc. Serial (lot) no. OWNPR'S COPY RABIES VACCINATION CERTIFICATE Owner's Name and Address NASPHV Form 4151 Rabies Tag Number PRINT - Last Print - use ball point pen or type First M.I. I Telephone (`4‘', ft/6 No. co4 'City em.te Zip - Species: Sex: Age: Size: Male 3 ma to 12 mo Under 20 Predominant Breed: Colors: Dog Cat 1 Female II( 12 moor olderl 20 - 50 lbs. lbs4 0 (Specify) Other: 0 Neutered 0 Actual Age 3 yy- Over 5011bs. Actual L.5. lbs. DATE VACCINATED: Producer: 2_1 0 e Veterinarian's: # (First 3 letters) (License No Month Day Year gA,X)y-tr, 0 1 yr. Lic./Vacc. VACCINATION EXPIRED: -1;t3 yr. Lk/Niece. Other 7;„fle, I/ S" Aas.isc.2F-) /S-.1)1611 Month Day Year Vacc. Serial (lot) no. 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 - Lisle First M.I. Telephone LACi,Olh6".6,4/6,019/ 10.14-9k-1-10i9 No. Lac) Mreet :..— ... /City 1 vv.., 1 ,crre„,13ikeera i_ak„, fihe.,45p12._ ifa 53 Species: Sex: Age: Size: Predominant Breed: Colors Dog 1. Male 0 3 mo to 12 mo 0 Under 20 lbs. 0 r r Cat Female .z( 12 mo or olderyl 20 - 50 lbs. -4 ----". t... 1 .• Other: 0 Neutered Actual Age3y r Over 50 lbs. 0 (Specify) Actualjalbs. Name: io Velick_ , DATE VACCINATED: Producer: Veterinarian's: # 7.- / / cense No) 1/ /1 (First 3 letters) ail, CrYji‘l'i Month Day Year 0 1 yr. Lic./Vacc. (Signature) Address : 3is .f E 1(C7/s7- - 14.yr. Uc./Vacc. VACCINATION EXPIRED: Other ii / 7 /Sal YEA Month Day Year Vacc. Serial (lot) no. 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 - Last,. / First M.I. Telephone CA4/0/1164v) Mivt . [Gr., No. 3.reoe i 1/4-4 r D City L 10/ state 2.. Sgros3 / errot_ tteiAA ,01,... / Species: Sex: Age: Size: Predominant Breed: Colo : Dog X Male i , 3 mo to 12 mo 0, Under 20 lbs.* ii 76241 Cat 0 Female 12 moor older 20 - 50 lbs. 0 j----01 60- C.- Other: 0 Neutered 0 Actual Age/ -I-' Over 50 lbs. 0 (SPecifY) -kyr Actual /6 lbs. Name: 6211_14 DATE VACCINATED: Producer: f Veterinarian's: # )12.-/ix.-9 (License No n k-,._A: (First 3 letters) 124 e Month Day Year Cl 1 yr. LiciVacc. (Signature) Address: 3.2" Fo, /SVS-i, "43 yr. Lic./Vacc. VACCINATION EXPIRED: Other 1;y1f4e, A.2....rolF) 1, y- ici /aA Month Day Year Vacc. Serial (lot) no. 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 - Las/ First M.I. Telephone 0)--i%"/O)r) istv No. "left 41-r) g i City State t rA7" / ofryr, _okiti_iv,. no-eit4ie i Species: * Sex: Age: Size: Predominant Breed: C ors: Dog Male 0 3 mo to 12 mo ID Under 20 lbs. O. Cat 0 Female yi 12 mo or older & 20 - 50 lbs. El ebitteitt Other: 0 Neutered 0 Actual Age p/4,- Over 50 lbs. 0 (Specify) Actuala_lbs NamA DATE VACCINATED: Producer: 2_ 0 _E. Veterinarian's: # (License /1)--Vir7 No.) (1 i'-' if (First 3 letters) 4 Month Day Year 0 1 yr. LicJVacc. (Signature) 3 ds- E-, 8---tt 37- Address: - V-3 yr. Lic./Vacc. VACCINATION EXPIRED: Other 7,- -v-p2.,A2p TS-4) 1/ if? /2-Pic5-014 Month Day Year Vacc. Serial (lot) no. OVVINER'S COPY RABIES VACCINATION CERTIFICATE Rabies Tag Number NASPHV Form #51 Owner's Name and Address Print - use ball point pen or type PRINT - 17t First M.I. Telephone *-- / AA/ ageinetA/J No. i , e",e,_ iity F71dg tr,4 1, ei-T6l b ,7)0e04 )1\374 Species: Sex: Age: Size: Predominant Breed: Colors: Dog Male 0 3 nno to 12 mo 0 Under 20 lbs.4 e %J Cat El Female s•Iti 12 mo or older4 20 - 50 lbs. 0 Other: Ill Neutered 0 Actual Age Over 50?,. 0 (Specify) Actual lbs Name , A Veterinarian's: # r(3-`' /47 DATE VACCINATED: Producer: 7.____ 0 (License No.) _il_ e- ii First 3 letters) aP/4 r, %).I-.07,04ree Month Day Year 0 1 yr. Lic./Vacc. (Sign ure) e)._S- f--4, ir4.5/ .. Address: 3 yr. Lic./Vacc. VACCINATION EXPIRED: Other 7 _Lt F 19 aciiA Month Day Year Vacc. Serial (lot) no. OWNER'S COPY RABIES VACCINATION CERTIFICATE Owner's Name and Address NASPHV Form #51 Rabies Tag Number -PRINT -.A4tt Print - use ball point pen or type First M.I. Telephone Liflep/n44Tvi ec ./c>/ ,0).--r c,zioi, No. 10_0) Street v i, .. riefy-r4etkr-t-6- szi AlateFs-o Species: Sex: Age: Size: a - Dog Male .17c 3 mo to 12 mIlli Under 20 lbs. CI Predominant Breed: Col : Cat 0 Female 0 12 mo or older 20 - 50 lbs. D S ly (SPecifY) Other: 0 Neutered* Actual Age Over 50 lbs. --lS Actual 9S lbs. Name: -Carr- DATE VACCINATED: _E I .., i i Producer: -7...._ (..) Veterinarian's: # / ense '-`-/ / No.) / 0 )0.1- i c (First 3 letters) ..--• Month Day Year 04 r7C-Pr%0-/ - 0 1 yr. Lic./Vacc. (signature} )itt yr. Lic./Vacc. Address: 3 .4.6-- E. if; M (Ft VACCINATION EXPIRED: Other lo a IF Toloe_,-A, 7-.-is.2r) s-i7S-7)- Month Day Year Vacc. Serial (lot) no.