BUCKEYE ANIMAL RESCUE.PDF

Maricopa County
Animal Care and Control
2500 South 27th Avenue
Phoenix, AZ 85009
(602) 506-7387 Tele.
(602) 506-2739 Fax
KENNEL PERMIT K17-000054
APPLICATION
El New •i! ) Renewal
Name: Lilia Mutka Kennel Name: Buckeye Animal Rescue
Mailing Address: 1919 N 200th Ave Kennel Address: Same
City: Buckeye State: AZ Zip: 85396 City: Buckeye Zip: 85396
County Supervisorial District: #4
Phone: 623-826-3085 Kennel Phone: 623-826-3085
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 AR. S. §11-
1008.
PLEASE ANSWER THE FOLLOWING QUESTIONS AND INITIAL EACH RESPONSE
1. INVe 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
riditions (ARS 11-1001).
1/We certify that 1NVe have 2,5 dogs and that the kennel meets the definition in statute.
3. ‘1 INVe 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.
(Vi9,,lations of license and leash laws DO NOT apply).
. I/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
maktqined on the premises for each dog.
5. qL-1,1 I /We certify that 1/We are submitting a valid copy of the rabies vaccination certificate for each
dog with this application.
6.1 IIWe understand that a dog remaining within the kennel is not required to be licensed individually under
A.R. 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 only being transported to another kennel which has a permit issued
under.this section.
• r.-1INVe understand that a person who fails to obtain a kennel permit under A.R.S.§11-1009 is subject to a
periay of twenty-five dollars in addition to the annual fee.
8. 1.$'' 1NVe understand that a person who knowingly fails to obtain a kennel permit within thirty days after
writteenotification 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
hess and is solely used for the purpose of licensing multiple dogs.
IANe certify that all of the information 1/We have provided is true and accurate under penalty of law.
j
Applicant Signature dita' Date: d6/40
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

' INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY
P, O. BOX 2508
CINCINNATI, OH 45201
MAR 1 1 205 Employer Identification Number:
Date: 46-3227031 '
DLN:
26053464002025
BUCKEYE ANIMAL RESCUE KENNEL Contact Person: '
1919 N 200TH AVENUE CUSTOMER SERVICE ID4 31954
BUCKEYE, AZ 85396-0000 Contact Telephone Number:
(877) 829-5500
Accounting Period Ending:
June 30
Public Charity Status:
- - 170(b) (1) (A) (vi)
Form 990/990-EZ/990-N Required:
Yes
Effective Date of Exemption:
July 15, 2013
Contribution Deductibility:
Yes
Addendum Applies:
No
Dear Applicant:
We're pleased to tell you we determined you're exempt from federal income tax
under Internal Revenue Code (INC) Section 501(c)(3). Donors can deduct
contributions they make to you under IRC Section 170. You're also qualified to
receive tax deductible bequests, devises, transfers or gifts under Section
2055, 2106, or 2522. This letter could help resolve questions on your exempt
status. Please keep it for your records.
Organizations exempt under IRC Section 501(c)(3) are further classified as
either public charities or private foundations. We determined you're a public
charity under the IRC Section listed at the top of this letter.
If we indicated at the top of this letter that you're required to file Form
990/990-EZ/990-N, our records show you're required to file an annual
information return (Form 990 or Form 990-EZ) or electronic notice (Form 990-N,
the e-Postcard). If you don't file a required return or notice for three
consecutive years, your exempt status will be automatically revoked.
If we indicated at the top of this letter that an addendum applies, the
enclosed addendum is an integral part of this letter.
For important information about your responsibilities as a tax-exempt
organization, go to www.irs.gov/charities . Enter "4221-PC" in the search bar
to view Publication 4221-PC, Compliance Guide for 501(c)(3) Public Charities,
which describes your recordkeeping, reporting, and disclosure requirements.
Letter 5435

Maricopa County Animal Care and Control
2500 S. 27th Avenue
Phoenix, AZ 85009-6797
(602) 506-7387
http://pets.maricoba.00v
Receipt Number: R16-250254 Receipt Date: 10/13/2016
Person ID: P2262784
Phone: 623 8263085
BUCKEYE ANIMAL RESCUE KENNELS 10/13/2016 10:42;14A1
1919 N 200TH AVE
BUCKEYE, AZ 85396
Item: Animal ID: Reference No: Price: Each: Amount:
KEN PERMIT A7777777 K17-000054 $328.00 1 $328.00
Total Fees Due: $328.00
Payments: Cash: $0.00
Check: $328.00
Credit Card: $0.00
Total Payments Received: 6328.00
Thank You!
Would you like to share your experience with our service to you? Change: $0.00
Please visit our website at http:fipets.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
saucedos WBUSOFF

Maricopa County
Animal Care & Control
2500 South 27 th Avenue
Phoenix, AZ 85009
Phone: (602) 506-7387
pets.inaricopa.gov
KENNEL PERMIT K17-000054
PREMISE INSPECTION
Number of Dogs: 25
Name: Lilia Mutka Kennel Name: Buckeye Animal Rescue
Mailing Address: 1919 N 200th Ave Kennel Address: Same
City: Buckeye State: AZ Zip: 85396 City: Phoenix Zip: 85396
County Supervisorial District: #4
Phone: 623-826-3085 Kennel Phone: 623-826-3085
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: 10/18/16
October 2015

11 c2 WM;CIINATICM CEVadFICAVE 0 0 3 4 1
Li
Veholey LC)Uhru(M - Official Proof of Vac -Ciliation
Ve0errilnary Sengices Keep this record in a safe place. Duplicate requests $10. Corporate Office Hours:
Mon - Fri 9:00 am - 500 pm
480-6994950 P.O. Box 7479•Mesa, AZ 85216
5ILLOWNER! Fill out sections #1-3 OFFICIAL RECORD - PLEASE PRINT CLEARLY WWVV.TLCVetServices.com
—f
Last Name: First Name:
DIL
Address:
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City: State:
Email:
Home: Work: -H
I acknowledge having read and I understand the back of this document. Being aware of e 6r
these facts, I give my permission to TENDER LOVING CARE VETERINARY SERVICES X DATE / ' /
LLC '-andlor the Doctor to treat and/or administer the vaccinations listed below There is a $1-$3 waste disposal fee per animal. Prescription ONLY fee $10.
New Client Yes No n Flow did you hear about this clinic? 11 Flyer from Store J Mailer Referral n Website n Other
PET #1 UliEk
0bog 0 Male 0 Neutered (male) CI On Medication VDog,ZIMale CI Neutered (male) 00n Medication
El Cat ni Female aSpayed (female) n Pregnant Cat El Female Spayed (female) 0 Pregnantzfr:"
Age (icheck one): r, 61 fkge (vc one):
ri Wks Wks
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PLEASE DO • NOT WRITE BELOW THIS LINE FOR OFFICE - USE 0 THIS LINE
Rabies Typi KILLED VIRUS Mig..: PRICE NEXT BOOSTERS Rabies Tge: I.0 ED 5 . PRIC NEXT BOOSTERS
3 4 6 12 36 \ - ' r: , ) # (n. not On 3 4 6
Weeks M(Entlis Months Monti s III ii. Efke Er 51E15 ) Weeks fichnis Willis k e Mhs
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PHYSICAL EXAM: PHYSICAL EXAM:
General Appearance i4 Qoioewi El Next Booster(s) Estimated Price $a.M1 1 General Appearance WarBal n Abfromal 0 Next Booster(s) Estimated Price $
Skin! Coat R NOTES! DOSAGE: n. Skin ! Coat 03 0 NOTES ! DOSAGE: (IL .
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HEALTH WITHIN-NORMAL LIMITS 1 HEALTH WITH1(l NORMT LIMITS
Yes NoEl Yes n No fl .
Vaccinations not delivered on schedule Varcination).not delivered on schedule
loose effectiveness. Returning after loose effectiveness. Returning after
the booster's clue date may require the booster's due date may require
additional vaccines for omprotection r, , -, ,f4__., additional vaccines for proper protection
at an additionally yuu AL 16 Utno IANYL, c---) at an additional cost to you. Sub Total: $‘.-a _ N
Veterinarian: Location: —cf Teph. !nit: --jcl CC Fee:
State Lb c # 1442 Date: ( Pd $ Bar $ CastiO) CC CI CVC Cashier hit: -VC )TOTAL: I
While: TLC VETERINARY SERVICES LLC CLIENT I COUNTY

RABIES VACCINATION CERTIFICATE
OWNER'S INFORMATION:
MUTKA LILIA P2285030 (623) 8263085
Uksl NAME FIRST NAME PERSON ID TELEPHONE NUMBER EXT:
1919 N 200TH AVE BUCKEYE
AZ 85396
STREET ADDRESS APT CITY STATE ZIP CODE
ANIMAL INFORMATION
DOG SPAYED 8/16/2015 LARGE SIBERIAN HUSKY MIX
ANIMAL TYPE ANIMAL SEX ANIP.IAL DATE OF BIRTH SIZE PRIMARY BREEb SECONDARY BREED
A3812942 KIARA BROWN WHITE
ANIMAL ID
ANIMAL NAME MICROCHIP NUMBER PRIMARY COLOR SECONDARY cOLOR
VACCINATION INFORMATION
RABDOMUN 12 Months 8/19/2016 8/19/2017 8/19/16
VACCINE PRODUCER VACC. LENGTH DATE VACCINATED VACCINATION EXPIRES PRINT DATE
Azii.Z,e4.."--
KILLED
Maricopa County
VACCINE TYPE Animal Care & Control
VETERINARIAN& SIGNATURE
2500 S 27th Avenue, Phoenix, AZ 85009
(602) 506-7387
SN120629
VACC. SERIAL No. VETERINARIANS UCENSE NUmHER

RABIES VACCINATION CERTIFICATE
OWNER'S INFORMATION:
i
MUTKA LILIA P2285030 (623) 8263085
LAST NAME FIRST NAME PERSON ID TELEPHONE NUMBER UM
1919 N 200TH AVE BUCKEYE AZ 85396
STREET ADDRESS APT CITY STATE ZIP CODE
ANIMAL INFORMATION
DOG SPAYED 6/3/2014 MED AUST SHEPHERD MIX
AN1P,u4. TYPE ANIMAL SEX ANIMAL DATE OF BIRTH SIZE PRIMARY BREED SECONDARY BREED
,
A3779618 0--- TRICOLOR WHITE
1:444-Tk—W/T/
ANiMAL JU ANMAL NAME MICROCHIP NUMBER PRIMARY COLOR SECONDARY COLOR
—
VACCINATION INFORMATION
RABDOMUN 12 Months 6/8/2016 6/8/2017 6/8/16
I
VACCINE PRODUCER VACC. LENGTH DATE VACCINATED VACCINATION EXPIRES PRMT DATE
4„,...i-,,ev..., C---,--___
KILLED Maricopa County
• - Animal Care & Control
VACCINE TYPE VET RINARIANS =NADAS
2500 S 27th Avenue, Phoenix, AZ 85009
(602) 506-7387
SN117129
VACC. SERIAL NO. VETERINARIAN'S LICENSE NumeLri

RABIES VACCINATION CERTIFICATE
OWNER'S INFORMATION:
MUTKA LILIA P2285030 (623) 8263085
LAST NAME FIRST NAME PERSON ID TELEPHONE NUMBER EXT:
1919 N 200TH AVE BUCKEYE AZ 85396
STREETADORESS , APT CRY STATE ZIP CODE
ANIMAL INFORMATION
DOG NEUTERED 5/27/2012 LARGE SAMOYED ALASKAN HUSKY
ANIMAL TYPE ANIMAL SEX ANIMAL DATE OF BIRTH SIZE PRIMARY SNEED SECONDARY BREED
WHITE
A3768049 1-1Lii5 99006,9°607161E32
ANIMAL 10 ANIML A NAME MICROCHIP NUMBER PRIMARY COLOR SEcoNDARY COLOR
VACCINATION INFORMATION
RABDOMUN 12 Months 6/1/2016 6/1/2017 6/2/16
VACCINE PRODUCER VACC. LENGTH 1 DATE VACCINATED VACCINATION EXPIRES PRINT DATE
A„, . Z At . i S -__A--,,s- - - - •
KILLED Maricopa County
Animal Care & Control
VACCINE TYPE _ _ -. VETERIFKRANS SIGNATURE 2500 S 27th Avenue, Phoenix, AZ 85009 - —
(602) 506-7387
SN117129
VACC. SERLAL NO. VETERINARIANS LICENSE NUMBER
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Dog ,. Male i] 3 Mo. to 12 Mo. 0 Under 20 lbs. l7 I
Cat ,- , . Female El 12 Mo. or older 0 20 - SO Ins .7 '
Other. Hi Altered 0 Over 50 lbs. 0 NAME:
(Specify) .., it 0 Male U Female Age
DATE VACCINATED: PRODUCER: • Veterinarian's It )rgies?
I '1 I i I : License No eezing 0 Appetite change
Month Day Year (Fits! 3 Letters) ‘leterinaria
VACCINATION EXPIRES: 1 yr. Lic./Vacc. H Signature
3 yr. Lic.Nacc. lil Addr ss . 45iia Spay I . Neuter . Clinic, . . Inc. - MESA
Month, Day Year ___ s . _ _ ______ - i 1.11e ,
Vacc. Serial (Lot) No, -WS-li r -AZ-SRN
; • I Phone: (480) 633-1734
VAC0410001
emia tested U Stray (past or present)
Has your pet ever been vaccinated? 0 Yes IJ No If Yes, in which month of this past year? Has it been over 1 year? 0 Yes Q No
Check those which apply Dog: U Parvo/Distemper combo CI Bordetella CI Rabies (Mo/Year)
Cat: Q FVRCP U Feline Leukemia U FIP U Rabies (MoNear)
hereby authorize the following: U SPAY (Female) U NEUTER (Male) CI Declaw You are 10 use all reasonable precautions against infuly, escape,
or death of my pet, but you will not be held liable or responsible
in any manner in connection therewith as it is Thoroughly under-
0 Dental c 21 Nail Trim U Ear Mite Treatment U Vaccinations stood That I assume all risks. I am aware that you are not 24
hour care facility.
Pain Med. U Lab IA Other
aDi Clrir 113 E L a WV/ S E Signature of Legal Owner or Authorized Person
Service $
Spay $
Neuter $
Declaw $
VAC
Nail Trim $ / - -
Dental $
HEAT $
Recovery Status . Pregnancy $
Weight Temp:' 'P /P Cryptorchid $
Vaccinations Given' Meds $
Ear mite Tx $
Medication Given'
Lab
Rx .
Heartworm $
i Veterinarian Signature:
Coupons (-)$
0 Booster Vacs needed in 3 Weeks U Annual Vacs in 1 year Li Return for suture removal (10-14 days)
LI Return in 6 mo. refill heartworm med. Testing: FELV FIV Heartworm TOTAL
$7° FEE FOR REPLACEMENT COPY or LOST RECORDS.

RABIES VACCINATION CERTIFICATE Tag fee $:
Tag it:
ADAPTED NASPHV FORM 51
Cert. Serial II:
PRINT - use boll point pen or type
Owner's Name & Address TWPH NE ta
kosit ?)i))36
glitikfu/
PRINT LAST S lP
NO. STREET e539&)
SIZE: PREDOMINANT BREED:
SPECIES: SEX: AGE: 171 CO61,1%-e-v
Male El 3 Mo. to 12 Mo. LI Under 20 lbs. 14 V S
Dog
Female 12 Mo. or older 20 - 50 lbs
Cat Over 50 lbs. D NAME: j,tJ IQ
Other 0 Altered
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DATE VACCINATED: PRODUCER: Veterinarian's
k '11 16 RiuiE
Month Day Year (First 3 Letters)
1 yr. Lic.Nacc.
VACCINATION EXPIRE ji
3 yr. Lic.Nacc.E] 1...1 51.03
Ji
Month Day Year Vacc. Serial (Lot) No.
VAC0410001
RABIES VACCINATION CERTIFICATE
Tag fee $:
ADAPTED NASPHV FORM 51 Tag #:
Owner's Name &Address PRINT - use ball point pen or type
Cert. Serial #:
PRINT LAST FIRST
MI
NO. STREET
SPECIES: SEX:
SIZE:
Dog Li Male
Cat D Under 20 lbs. D
Female
20 - 50 lbs
Other 0 Altered
Over 50 lbs.
(Specify)
T3-R771
Month
(First 3 Letters)
Veterinarian's
1 yr. LiC.Nacc.A.
VACCFNATION Expr,
Signature
3 yr. Lic.Nacc. o
Lets-d 4-( Address
Month Day Year
Vacc. Serial (Lot) No.
VAC0410001

RABIES VACCINATION CERTIFICATE Tag lee $:
-., ADAPTED NASPHV FORM 51 Tag II:
Owner's Name & Address PRINT - use ball point pen or type Cert. Serial II:
PRINT: LAST . FIRST . MI TELEPHONE /
r.
-'1 1 r , t
NO STREET CITY • STATE ZIP ,
SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS:
Dog p Male LI 3 Mo. to 12 Mo. ri Under 20 lbs. li
Cat 0 Female Li 12 Mo or older Li 20 - 50 lbs El
'
Other 0 Altered N Over 50 lbs. Li NAME:
(Specify)
DATE VACCINATED: PRODUCER:
Veterinarian's It i
License No.
Month Day Year .
(First 3 Letters) Veterinarian's
1 yr. Lic.Nacc. 0
VACCINATION EXPIRES: Signature
3 yr. Lic.Nacc. 1-1'
Address ,__
Month Day Year , i• I
Vacc. Serial (Lot) No.
VAC0410001
I.I
RABIES VACCINATION CERTIFICATE Tag fee $:
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ADAPTED NASPHV FORM 51 Tag II:
Owner's Name & Address PRINT - use ball point pen or type Cert. Serial if:
PRINT LAST FIRST MI TELEPHONE
NO. STREET CITY STATE ZIP
SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS:
Dog 1.1 Male 0 3 Mo. to 12 Mo. 11 Under 20 lbs. 0 ''','' i.. ':' "
— , ,
Cat Li Female ,.[;_l 12 Mo. or older Li 20 - 50 lbs Li
Olher II Altered Id Over 50 lbs. rl NAME:
Li il
(Specify) '
DATE VACCINATED: PRODUCER:
Veterinarian's II
License No
Month Day Year (First 3 Letters)
Veterinarian's
1 yr. Lic.Nacc...„ Signature
VACCINATION EXPIRES: •
3 yr. Lic.Nacc. E.] Address ,._ •
Month Day Year - ' ' i 1 C (- — -,---,
Vacc. Serial (Lot) No.
VAC0410001
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RABIES VACCINATION CERTIFICATE Tag fee $:
ADAPTED NASPHV FORM 51 Tagil:
Owner's Name & Address PRINT - use ball point pen or type Cert. Serial #:
PRIM_IN FIRS ith n a 6Az TpAPHZNE 73 _
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No, 4 yit ZIP 4 g 63 9 to
SPECIES: SEX: AGE: SIZE: PREDSTANT BREED: COLaa ok
Dog $ Male D 3 Mo. to 12 Mo. 0 Under 20 lbs. 0 160 V,,
Cat 0 Female X 12 Mo. or older K 20 - 50 lbs YS
Other 0 Altered )ifl . __ Over — 50 lbs. - p NAME: _ _ - -
(Specify)
Plri"6
DATE VACCINATED: PRODUCER:
Veterinarian's #
1 .S' 1 6 0 E License No.
Month Day Year (First 3 Letters) /
Veterinarian's
1 yr. Lic.Nacc*
VACCINATION EXPIRES: Signature
ri 3 yr. Lic.Nacc. 0
Add ress
Month Day Year t)__)S41 3A
Vacc. Serial (Lot) No. Vek"
VAC0410001
RABIES VACCINATION CERTIFICATE Tagfee $:
ADAPTED NASPH V FORM 51 Tag //:
Owner's Name & Address PRINT - use ball point pen or type Cert. Serial #:
PRINT LASTiiie kg y211,S Wink/ jelj Nit" licii?
Tglf RHONE
72-. AO
NO. STREET at STATE ZIP
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053940
SPECIES: 1 SEX: AGE: SIZE: PREDOMINANT BREED: COLO*: A 1
Dog Male 0 3 Mo. to 12 Mo. El under 20 /las. El \ 4-(iS krytd4 ro,t, A
Cat 0 Female N, 12 Mo. or older FL 20 - 50 lbs 0 /sue/L._
Other 0 Altered _IIV Over 50 lbs. NAME:
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DATE VACCINATED: PRODUCER:
Veterinarian's . #
t Li 1 6 1. a License No.
Month Day Year (First 3 Letters) I1111111. err
Veterinarian's
1 yr. Lic.Nacc.K Air
VACCINATION EXPIRES: RES: Signature 406,
( ) 3 yr. Lic.Nacc. 0 ).._( 9+13 4
Addre
Month Day Year Vq_+CIO 5
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Vacc. Serial (Lot) No.
VAC0410001

RABIES VACCINATION CERTIFICATE Tag fee $:
ADAPTED NASPHV FORM 51 Tag #:
Owner's Name & Address PAINT - use ball point pen or type Cert. Serial #:
PRINT LAS ley__ FIRST
MI TELEPHONE 62.-2
6tiottai„. Itto . 36"g6
NO. STREET
STATE az, ZIP
SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS:
Dog , Male 0 3 Mo. to 12 Mo , 0 Under 20 lbs. 0
Cat Female A 12 Mo. or older if] 20 - 50 ibs
Other 0 Altered Over 50 lbs. D NAME:
(Specify)
DATE VACCINATED: PRODUCER:
Veternarian's # "
'cense No.
Month Day Year
(First 3 Letters)
Veterinarian
1 yr. Lic.Nacc.k
VACCINATION EXPIRES: Signature
145 I 3 yr. Lic./Vacc. a
-- 7 Address
Month Day Year
Vacc. Serial (Lot) No.
RABIES VACCINATION CERTIFICATE Tag fee $:
ADAPTED NASPHV FORM51 Tag It:
Owner's Name & 44_ Address PRINT - use ball point pen or type Cert. Serial #:
PRINT LAS FIRST MI TELEPHONE to-z 3
43 tto . 3 0
NO. STREET ET gikelt crry . 0 STAR. 4 ZIP 5 3 q 49
SPECIES: . SEX: AGE: SIZE: PREDOMINANT BREED: COLORS:,
Dog '1%. Male D 3 Mo. to 12 Mo. 0 Under 20 lbs. 0 kly..3k 4,4
Cat CI Female 1:6` I 12 Mo, or older ii,. 20 -.50 lbs 0 * --- UjAktC--
Other El Altered lit Over 50 lbs. 0 NAME:
/ n
(Specify) I ,.`..,"Ik_ \
DATE VACCINATED: PRODUCER: , ':-/-N(.5 C
Veterinarian's # '- ' *1 .-
C,I k ) I-.11 E License No.
Month Day Year / '
( First 3 Letters) Veterinarian's
1 yr. Uc.Nacc. 0 Signature
VACCINATION EXPIRES:
c; ( , _;1 3 yr. LiciVacc. Address V _
.. ) I i4-f 'I /1.
Month Day Year
Vacc. Serial (Lot) No.
VAC0410001

VACC1HATHON CERTF1CAitE
#: 6316 Animal: Antonio Bandera
Owner: Lilia Mutka 3/15/74 BARK Species: Canine
Address: 1919 N. 200th Ave Breed: German Shep X
Buckeye, AZ 85396 Color: TR1
Gender: Male Neutered
Phone: (623)826-3085 Birthdate:
(602)212-6700 Age:
Weight: 18.15
Chip #:
Vaccine Manufacturer Serial # Type Tag # Due
10/05/2016 Rabies-Rescue 1 year ZOE 120622 Killed 10/04/2017
(w/Surgery)
Mobile Animal Surgical Hospital, Inc.
9716 E. Cholla Street
Scottsdale, AZ 85260 e Minn loIS
(480) 656-4479 31111a Neufeld, DVM 010512016
mashapptsgaacom • E9WW.IiiaSh vet. et 3538

VACCINATION CERTIFICATE
Account #: 6316 Animal: Suzette
Owner: Lilia Mutka 3115/74 BARK Species: Canine
Address: 1919 N. 200th Ave Breed: German Shep X
Buckeye, AZ 85396 Color: BRN BLK
Gender: Female Spayed
Phone: (623)826-3085 Birthdate:
(602)212-6700 Age:
Weight: 19.02
Chip #:
Date VEM11711 Manufacturer Serial # Type Tag # C11 1717P
10/05/2016 Rabies-Rescue 1 year ZOE 120622 Killed 10/04/2017
(w/Surgery)
Mobile Animal Surgical Hospital, Inc.
9716 E. Cholla Street
Scottsdale, AZ 85260 e. qiv i/s Ji
(480) 656-4479 Julil Neufeld, DVM 10/05/2016
mashappts@itoLcom • www.nzashvetnet 3538

VACCMAinON CERIVICATE
Account if: 6316 Animal: Romeo
Owner: Lila Mutka 3/15/74 BARK Species: Canine
Address: 1919 N. 200th Ave Breed: German Shep X
Buckeye, AZ 85396 Color: BLIC/VVIIT
Gender: Male Neutered
Phone: (623)826-3085 Birthdate:
(602)212-6700 Age:
Weight: 18.04
Chip #:
C171117 GTE= Manufacturer MITIE Type Tag # Due on
10/05/2016 Rabies-Rescue 1 year ZOE 120622 Killed 10/04/2017
(w/Surgety)
TWobil(? Animal Surgical Hospital, Inc.
9/16 E. Cholla Street
,geottsdole, AZ 85260 10) SI 16
(480) 656-4479 Julia Neufeld, DVM 10/05/2016
washapptsca),aol. Co www.mashvet.net 3538

VACCRIATION CERIRRCATE
Account #: 6316 Animal: Percy
Owner: Lilia Mutka 3/15/74 BARK Species: Canine
Address: 1919 N. 200th Ave Breed: German Shep X
Buckeye, AZ 85396 Color: GRE/TAN
Gender: Female Spayed
Phone: (623)826-3085 Birthdate:
(602)212-6700 Age:
Weight: 44.40
Chip #:
10/05/2016 Rabies-Rescue 1 year
(w/Surgery)
Mobile Animal Surgical Hospital, line.
9716 E. Cho/la Street
Scottsdale, AZ 85260 uiA-le-t V. 41.4agi,.., NM It) IS ) tG,
(480) 656-4479 Jul n a Neufeld, DVM 1 /05 2016
inashappts(iaoLCOM ° www.mashvet.net 3538