Extracted text (via pymupdf_layout)
32203 characters
Maricopa County
Animal Care and Control
2500 South 27th Avenue
Phoenix, AZ 85009
(602) 506-7387 Tele.
(602) 506-2739 Fax
KENNEL PERMIT APPLICATION
/6
1117- lew)D Renewal Permit # KI4-000059
Name: Judy Hamel Kennel Name: Forever Faithful
Mailing Address: PO Box 7753 Kennel Location: 12613 S 189th Ave 31A.c/42/y. AZ F3'3,2 k
City: Goodyear AZ ZIP: 85338 County Supervisorial District: 5
Phone: 623-810-1622 Kennel Phone: 623-810-1622
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.
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. 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
I. I/We assume complete responsibility for the kennel at the premises for which I/we are making
appli ation 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. q\bt INVe certify that I/We have 146 dogs and that the kennel meets the definition in statute.
3. I/We certify that I/We have not been convicted of a violation of A.R.S. §§ 13-2910 (cruelty to animals)
or -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. IANe certify that all dogs over the age of three (3) months that are kept, harbored or maintained on the
preiliiises 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. I NVe certify that I/We are submitting a valid copy of the rabies vaccination certificate for each
dog with this application.
6. INVe understand that a dog remaining within the kennel is not required to be licensed individually under
A.Ith 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.
7. INVe understand that a person who fairs to obtain a kennel permit under A.R.S.§11-1009 is subject to a
pe9ey of twenty-five dollars in addition to the annual fee.
8.Ch INVe understand that a person who knowingly fails to obtain a kennel permit within thirty days after
written notification from the county enfortement agent is guilty of a class 2 misdemeanor..
9. The undersigned understand that that the kennel permit does not authorize the operation of any type
of .! siness and is solely used for the purpose of licensing multiple dogs.
INVe certify that all of the information 1/We have provided is true and accurate under penalty of law.
Applicant Signature QsAkiik A, t4cAzry.)„\ Date: Ao/o2-6//6---
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
2 of 2
Maricopa County
Animal Care & Control
2500 South 27th Avenue
Phoenix, AZ 85009
Phone: (602) 506-7387
pets.maricopa.gov
KENNEL PERMIT PREMISE INSPECTION
Name: Judy Hamel Kennel Name: Forever Faithful
Mailing Address: PO Box 7753 Kennel Location: 12613 S 189th Ave
c A z, 8-S34r
City: Goodyear AZ ZIP: 85338 County Supervisorial District: 5
Home Phone: 623-810-1622 Kennel Phone: 623-810-1622
1. Are all dogs over the age of three months properly vaccinated for rabies and in possession of a
valid rabies vaccination certificate?
YES
NOTE: Copies of each rabies vaccination certificate must be attached to the Kennel Permit
Premise Inspection form.
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
CORRECTIVE ACTION NEEDED FOR COMPLIANCE AND ilf DAYS GIVEN
BEFORE REINSPECTION. (Note: There will be $49 re-inspect fee pay le to the Inspector by
check upon each return visit.)
N/A
Deputy Enforcement Agent 14_7_ Date
Maricopa County Animal Care and Control
2500 S. 27th Avenue
Phoenix, AZ 85009-6797
(602) 506-7387
http://pets.maricopadov
Receipt Number: R15-128896 Receipt Date: 06/0312015
S. /Yff 4„ Person ID: P2360063
0643 Phone: 623 8101622
FOREVER FAITHFUL KENNELS 660dyar 42 6/3/2015 12:54:35PM
PO BOX 7753
GOODYEAR, AZ 85338
qw- / 2-
Item: Animal ID: Reference No: Price: Each: Amount:
KEN PERMIT A7777777 K15-000059 $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 hftp://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
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Date of Rabies Vaccination: 08-13-15 Next Rabies Vaccination On: 08-12-18
VETERINARY CLINIC OWNER OF ANIMAL
Bethany Animal Hospital 2015 Judy Harnel Forever Faithful An Sanct
2524 W Bethany Home Rd. PO BOX 7753
Phoenix, AZ 85017 Goodyear, AZ 85338
602-242-1657 810-1622
This is to certify...
THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.
PATIENT: Toby SEX: Neutered Male
SPECIES: Canine WEIGHT: 80.00
BREED: Shepherd mix AGE: 3Y
Color and markings: Tan DOB: 08-13-12
ete.141-2,46. _
Signed
Rustin Bodiker License: 6605
Rabies Vaccine Information...
MFG BY: RABVA SER.NO: S516083B Name: Nobivac 3
TYPE: KIL ADM: SQ
SUBMIT WITH LICENSE APPLICATION
CUT HERE
Date of Rabies Vaccination: 08-13-15 Next Rabies Vaccination On: 08-12-18
VETERINARY CLINIC OWNER OF ANIMAL
Bethany Animal Hospital 2015 Judy Hamel Forever Faithful An Sanct
2524 W Bethany Home Rd. PO BOX 7753
Phoenix, AZ 85017 Goodyear, AZ 85338
602-242-1657 810-1622
This is to certify...
THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.
PATIENT: Toby SEX: Neutered Male
SPECIES: Canine WEIGHT: 80,00
BREED: Shepherd mix AGE: 3Y
Color and markings: Tan BOB: 08-13-12
4,04-
Signed
Rustin Bodiker , License: 6605
Rabies Vaccine Information...
MFG BY: RABVA SER.NO: S516083B Name: Ncipivac 3
TYPE: KIL ADM: SQ
OWNER COPY- KEEP IN A SAFE PLACE
Date of Rabies Vaccination: 08-17-15 Next Rabies Vaccination On: 08-16-18
VETERINARY CLINIC OWNER OF ANIMAL
Bethany Animal Hospital 2015 Judy Hamel Forever Faithful An Sanot
2524 W Bethany Home Rd, PO BOX 7753
Phoenix, AZ 85017 Goodyear, AZ 85338
602-242-1657 810-1622
This is to certify...
THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.
PATIENT: Thelma SEX: Female
SPECIES: Canine WEIGHT: 30.20
BREED: Spaniel Mix AGE: 3Y
Color and markings: Brown DOB: 08-17-12
Signed
Rustin Bodiker License: 6605
Rabies Vaccine Information._
MFG BY: RABVA SER.NO: S516083B Name: Nobivac 3
TYPE: KIL ADM: SO
SUBMIT WITH LICENSE APPLICATION
CUT HERE
Date of Rabies Vaccination: 08-17-15 Next Rabies Vaccination On: 08-16-18
VETERINARY CLINIC OWNER OF ANIMAL
Bethany Animal Hospital 2015 Judy H:,- ffnel Forever Faithful An Saret
2524 W Bethany Home Rd. PO BOX 7753
Phoenix, AZ 850 .17 Goodyear, AZ 85338
602-242-1657 810-1622
This is to certify...
THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL. DESCRIBED BELOW.
PATIENT: Thelma SEX: Female
SPECIES: Canine WEIGHT: 30.20
BREED: Spaniel Mix AGE: 3Y
Color and markinu-s: Brown DOB: 08-17-12
Signed
Rustin Bodiker License: 6605
Rabies Vaccine Information...
MEG BY: RABVA SER.NO: 35160830 Name: Nobivac 3
TYPE: KIL ADM: SO_
OWNER COPY- KEEP IN A SAFE PLACE
Date of Rabies Vaccination. 08-1-15 Next Rabies Vaccination On: 08-10-18
VETERINARY CLINIC OWNER OF ANIMAL
Bethany Animal Hospital 2015 Judy Hamel Forever Faithful An Sanct
2524 W Bethany Home Rd. PG BOX 7753
Phoenix, AZ 85017 Goodyear, AZ 85338
602-242-1657 810-1622
This is to certify...
THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.
PATIENT: Queenie SEX: Spayed Female
SPECIES: Canine WEIGHT: 18.40
BREED: Chihuahua, Short-hair Mix AGE: 10Y
Color and markings: Tan DOB: 04-09-05
Signed
Done Anderssohn License: 4007
Rabies Vaccine Information...
MEG BY: RABVA SER.NO: 3516083B Name: Nobivac 3
TYPE: Mt_ ADM: SQ
SUBMIT WITH LICENSE APPLICATION
CUT HERE
Date of Rabies Vaccination: 08-11-15 Next Rabies Vaccination On: 08-10-18
VETERINARY CLINIC OWNER OF ANIMAL
Bethany Animal Hospital 2015 Judy Hamel Forever Faithful An Sanct
2524 W Bethany Home Rd. PO BOX 7753
Phoenix, AZ 85017 Goodyear, AZ 85338
602-242-1657 810-1622
This is to certify...
THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.
PATIENT: Queenie SEX: Spayed Female
SPECIES: Canine WEIGHT: 18.40
BREED: Chihuahua, Short-hair Mix AGE: 10Y
Color and markims: Tan DOB: 04-09-05
Signed
Done Anderssolin License: 4007
Rabies Vaccine Information...
MEG BY: RABVA SER.NO: 3516083B Name: Nobivac 3
TYPE: KIL ADM: SQ
OWNER COPY- KEEP IN A SAFE PLACE
Date of Rabies Vaccination: 08-13-15 Next Rabies Vaccination On: 08-12-16
VETERINARY CLINIC OWNER OF ANIMAL
Bethany Animal Hospital 2015 Judy Hamel Forever Faithful An Sanct
2524 W Bethany Home Rd. PO BOX 7753
Phoenix, AZ 85017 Goodyear, AZ 85338
602-242-1657 810-1622
This is to certify...
THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.
PATIENT: Ivan SEX: Neutered Male
SPECIES: Canine WEIGHT: 73.40
BREED: Pit Bull Mix AGE: 2Y
Color and markings: Brown DOB: 03-05-13
Signed
Rustin Bodiker License: 6605
Rabies Vaccine Information._
MFG BY: RABVA SER.NO: S516083B Name: Nobivac 3
TYPE: KIL ADM: SQ
SUBMIT WITH LICENSE APPLICATION
CUT HERE
Date of Rabies Vaccination: 08-13-15 Next Rabies Vaccination On: 08-12-16
VETERINARY CLINIC OWNER OF ANIMAL
Bethany Animal Hospital 2015 Judy Hamel Forever Faithful An Sanct
2524 W Bethany Home Rd. PO BOX 7753
Phoenix, AZ 85017 Goodyear, AZ 85338
602-242-1657 810-1622
This is to certify...
THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.
PATIENT: Ivan SEX: Neutered Male
SPECIES: Canine WEIGHT: 73.40
BREED: Pit Bull Mix AGE: 2Y
Color and markings: Brown DOB: 03-05-13
Signed
Rustin Bodiker License: 6605
Rabies Vaccine Information...
MFG BY: RABVA SER.NO: S516083B Name: Nobivac 3
TYPE: KIL ADM: SQ
OWNER COPY- KEEP IN A SAFE PLACE
,
Date of Rabies Vaccination: 03-04-15 Next Rabies Vaccination On: 03-M-16
VETERINARY CLINIC OWNER OF ANIMAL
Bethany Animal Hospital 2015 Judy Hamel Forever Faithful An Sanct
2524 W Bethany Home Rd. PO BOX 7753
Phoenix, AZ 85017 Goodyear, AZ 85338
602-242-1657 810-1622
This is to certify...
THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.
PATIENT: Moxie SEX: Spayed Female
SPECIES: Canine WEIGHT: 8.81
BREED: Chihuahua AGE: 12M
Color and markings: Tan DOB: 03-03-14
Signed
Katharine D. An License: 3442
Rabies Vaccine Information...
MFG BY: ZOETI SER.NO: S407983 Name: Nobivac 3
TYPE: K1L ADM: SQ
SUBMIT WITH LICENSE APPLICATION
CUT HERE
Date of Rabies Vaccination: 03-04-15 Next Rabies Vaccination On: 03-03-16
VETERINARY CLINIC OWNER OF ANIMAL
Bethany Animal Hospital 2015 Judy Hamel Forever Faithful An Sanct
2524 W Bethany Home Rd. PO BOX 7753
Phoenix, AZ 85017 Goodyear, AZ 85338
602-242-1657 810-1622
This is to certify...
THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.
PATIENT: Moxie SEX: Spayed Female
SPECIES: Canine WEIGHT: 8.81
BREED: Chihuahua AGE: 12M
Color and markings: Tan DOB: 03-03-14
Signed mgL,
Katharine D. Andre, DVM License: 3442
Rabies Vaccine Information...
MFG BY: ZOETI SER.NO: S407983 Name: Nobivac 3
TYPE: KIL ADM: SQ
OWNER COPY- KEEP IN A SAFE PLACE
Date of Rabies Vaccination. 08-18-15 Next Rabies Vaccination On: 08-17-18
VETERINARY CLINIC OWNER OF ANIMAL
Bethany Animal Hospital 2015 Judy Hamel Fol ever Faithful An Sanct
2524 W Bethany Home Rd. PO BOX 7753
Phoenix, AZ 85017 Goodyear, AZ 85338
602-242-1657 810-1622
This is to certify...
THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.
PATIENT: Luckie SEX: Neutered Male
SPECIES: Canine WEIGHT: 55.00
BREED: Chow Chow Mix AGE: 8Y
Color and markings: Red DOB: 08-20-07
Signed
Rustin Bodiker License: 6605
Rabies Vaccine Information...
MFG BY: RABVA SER.NO: S516083B Name: Nob ivac 3
TYPE: KIL ADM: SQ
SUBMIT WITH LICENSE APPLICATION
CUT HERE
Date of Rabies Vaccination: 08-18-15 Next Rabies Vaccination On: 08-17-18
VETERINARY CLINIC OWNER OF ANIMAL
Bethany Animal Hospital 2016 Judy Hamel Forever Faithful An Sanct
2524 W Bethany Home Rd. PO BOX 7753
Phoenix, AZ 85017 Goodyear, AZ 85338
602-242-1657 810-1622
This is to certify...
THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.
PATIENT: Luckie SEX: Neutered Male
SPECIES: Canine WEIGHT: 55.00
BREED: Chow Chow Mix AGE: BY
Color and markings: Red BOB: 08-20-07
Signed
IRustin Bodiker License: 6605
Rabies Vaccine Information...
MFG BY: RABVA SER.NO: S516083B Name: Nobivac 3
TYPE: KIL ADM: SO
OWNER COPY- KEEP IN A SAFE PLACE
Date of Rabies Vaccination: 03-04-15 Next Rabies Vaccination On: 03-03-16
VETERINARY CLINIC OWNER OF ANIMAL
Bethany Animal Hospital 2015 Judy Hamel Forever Faithful An Sanct
2524 W Bethany Home Rd. PO BOX 7753
Phoenix, AZ 85017 Goodyear, AZ 85338
602-242-1657 810-1622
This is to certify...
THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.
PATIENT: Marilyn SEX: Spayed Female
SPECIES: Canine WEIGHT: 10.94
BREED: Chihuahua AGE: 12M
Color and markinus: White DOB: 03-03-14
Signed
Katharine D. Andre, DVM License: 3442
Rabies Vaccine Information...
MFG BY: ZOETI SER.NO: 5407983 Name: Nobivac 3
TYPE: KIL ADM: SQ
SUBMIT WITH LICENSE APPLICATION
CUT HERE
Date of Rabies Vaccination: 03-04-15 Next Rabies Vaccination On: 03-03-16
VETERINARY CLINIC OWNER OF ANIMAL
Bethany Animal Hospital 2015 Judy Hamel Forever Faithful An Sanct
2524 W Bethany Home Rd. PO BOX 7753
Phoenix, AZ 85017 Goodyear, AZ 85338
602-242-1657 810-1622
This is to certify...
THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.
PATIENT: Marilyn SEX: Spayed Female
SPECIES: Canine WEIGHT: 10.94
BREED: Chihuahua AGE: 12M
Color and markings: „White DOB: 03-03-14
Signed
Katharine D. Andre, DVM License: 3442
Rabies Vaccine Information...
MFG BY: ZOETI SER.NO: S407983 Name: Nobivac 3
TYPE: KIL ADM: SQ
OWNER COPY- KEEP IN A SAFE PLACE
Date of Rabies Vaccination: 03-17-15 Next Rabies Vaccination On: 03-16-16
VETERINARY CLINIC OWNER OF ANIMAL
Bethany Animal Hospital 2015 Judy Hamel Forever Faithful An Sanot
2524 W Bethany Home Rd. PO BOX 7753
Phoenix, AZ 85017 Goodyear, AZ 85338
602-242-1657 810-1622
This is to certify...
THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.
PATIENT: Frankie SEX: Neutered Male
SPECIES: Canine WEIGHT: 13.19
BREED: Chihuahua, Short-hair Mix AGE: 9M
Color and markings: Black & White DOB: 11-01-14
Signed
Done Anderssohn License: 4007
Rabies Vaccine Information...
MFG BY: ZOETI SER.NO: 5407983 Name: Nobivac 3
TYPE: KIL ADM: SQ
SUBMIT WITH LICENSE APPLICATION
CUT HERE
Date of Rabies Vaccination • 03-17-15 Next Rabies Vaccination On: 03-16-16
VETERINARY CLINIC OWNER OF ANIMAL
Bethany Animal Hospital 2015 Judy Hamel Forever Faithful An Sanct
2524 W Bethany Home Rd. PO BOX 7753
Phoenix, AZ 85017 Goodyear, AZ 85338
602-242-1657 810-1622
This is to certify...
THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.
PATIENT: Frankie SEX: Neutered Male
SPECIES: Canine WEIGHT: 13.19
BREED: Chihuahua, Short-hair Mix AGE: OM
Color and markings: Black & White DOB: 11-01-14
JAlikAdi
Signed o,‘ •
Done Anderssohn License: 4007
Rabies Vaccine Information...
MFG BY: ZOETI SER.NO: S407983 Name: Nobivac 3
TYPE: KIL ADM: SQ
OWNER COPY- KEEP IN A SAFE PLACE
Date of Rabies Vaccination 08-11-15 Next Rabies Vaccination On: 08-10-18
VETERINARY CLINIC OWNER OF ANIMAL
Bethany Animal Hospital 2015 Judy Hamel Forever Faithful An Sanct
2524 W Bethany Home Rd. PO BOX 7753
Phoenix, AZ 85017 Goodyear, AZ 85338
602-242-1657 810-1622
This is to certify...
THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.
PATIENT: Brownie SEX: Neutered Male
SPECIES: Canine WEIGHT: 57.80
BREED: Pit Bull AGE: 12Y
Color and markings: Brown BOB: 08-14-03
Signed 7C/11111 (41-04 4 5474
Done Anderssohn License: 4007
Rabies Vaccine Information...
MFG BY: RABVA SER.NO: S5160836 Name: Nobiyac 3
TYPE: KIL ADM: SQ
SUBMIT WITH LICENSE APPLICATION
CUT HERE
Date of Rabies Vaccination: 08-11-15 Next Rabies Vaccination On: 08-10-18
VETERINARY CLINIC OWNER OF ANIMAL
Bethany Animal Hospital 2015 Judy Hamel Forever Faithful An Sant
2524 W Bethany Home Rd. Po BOX 7753
Phoenix, AZ 85017 Goodyear, AZ 85338
602-242-1657 810-1622
This is to certify...
THAT I HAVE VACCINATED AGAINST RABiES THE ANIMAL DESCRIBED BELOW.
PATIENT: Brownie SEX: Neutered Male
SPECIES: Canine WEIGHT: 57.80
BREED: Pit Bull AGE: 12Y
Color and markings: Brown BOB: 08-14-03
Signed
Done Anderssohn License: 4007
Rabies Vaccine Information...
MFG BY: RABVA SER.NO: S516083B Name: Nobiyae 3
TYPE: KIL ADIVI: SQ
OWNER COPY- KEEP IN A SAFE PLACE
08/14/2015 0:01 6022425573 BETHANY ANIMAL HSPTL HA6t U1/111
Date of Rabies Vaccination: 02-10-15 Next Rabies Vaccination On: 6 )-1
VETERINARY CLINIC OWNER 2015 Judy OF Hamel ANIMAL Forever Faithful n Snot
Bethany Animal Hospital PO BOX 7753
2524 W Bethany Home Rd. Goodyear, AZ 85338
Phoenix, AZ 85017 • 810-1622 1 ;
602-242-1857
This THAT is I to HAVE certify... VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW,
PATIENT; Tommie SEX; Neutered Male
SPECIES: canine WEIGHT; 8.50
BREED: Chihuahua AGE: 18M
Color and markings: Tan & Black DOB: 02,10 -14
Signed License; 4007
Dore Anderssohn
Rabies Vaccine Information...
MEG BY; 70E11 SER.NO: 8407983 Name: Nobivac 3
TYPE; KIL ADM: SQ
SUBMIT WITH LICENSE APPLICATION
CUT HERE
Date of Rabies Vaccination: 02- 10-15 Next Rabies Vaccination Or0;01-10-1
VETERINARY CLINIC OWNER 2016 ',.).udy OF Hamel ANIMAL Forever Faithfu) An qanct
Bethany Animal Hospital PO BOX 7763
2524 W Bethany Home Rd. Goodyear, AZ 95338
Phoenix, AZ- 86017 010-1622
602-242-1657
THAT This is I to HAVE Certify... VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.:
PATIENT: Tommie SEX: Neutered Male
SPECIES: Canine WEIGHT: 8.50
BREED: Chihuahua AGE: 18M
Color and mKkings: Tan & Black DOB: 02 - 10 -14
Signed — License: 4007
Done Anderssohn
Rabies Vaccine Information_
MEG BY: ZOETI SER,NO: 8407983 Name: Nobivac 3
TYPE: KIL ADM: SO
OWNER COPY- KEEP IN A SAFE PLACE
RABIES VACCINATION CERTIFICATE Tag fee $: 3chool Pet Clinic, Rd., LLC 4108
ADAPTED NASPHV FORM 51 Tag It: AZ 85033
Owner's Name & Address PRINT - use ball point pen or type Cert. Serial #: 46-3979
PRINT FIRSI TELEPHONE
-FAO rYAL _..3 L t A -Frm \)er frct 11-14x i V.-3 810
NO STREET CITYr.„ i STATE ZIP , lame Phone .
0 A04. —11S 3 U 006•-lear 5 -5- 331 . Day Phone .
SPEC ES: SEX:, AGE: - SIZE: PREDOMINANT BREED: COLORS:
Dog I Male 3 Mo. to 12 Mo. till Under 20 lbs. .--1-- (A. h
Cat Female 0 12 Mo, or older 0 - 50 lbs ri 0',W1, ify\' I y
Other I: Altered Over 50 lbs. 17 NAME.
(Specify) ItD lild \ n' 4
) Cat t) Male Female Agoz.i
DATE VACCINATED: PRODUCER:
Veterinarian's # I /Allergies? •••
L 30 i S-- R n Q License No.
Month Day Year (First 3 Letters) '/Sneezing 0 Appetite change
Veterinarian's
VACCINATION EXPIRES: 1 yr. Lic.Nacc.X Signature a._ c3ii---- -
q 30 k0 3 yr. Lic.Nacc. C AddresPPAY AND NE TER CLINIC
Month Day Year ) 7, 1 S LI 0 (4 q 7342W. Indian School Rd., Ste 108
Vacc. Serial (Lot) No. Phoenix r0_33 A2_85
523-846-3979
C0410001
.eukernia tested U Stray (past or present)
Has your pet ever been vaccinated? U Yes LI No If Yes, in which month of this past year? Has it been over 1 year? U Yes Ei No
Check those which apply Dog: U Parvo/Distemper combo IJ Bordetella U Rabies (MoNear)
Cat: U FVRCP Li Feline Leukemia U FIP LI Rabies (MoNear)
I hereby authorize the following: ID SPAY (Female) U NEUTER (Male) U Declaw You are to use all reasonable precautions against injury, escape. II
or death of Iny pet, but you will not be held liable or responsible
Ei Dental 0 Nail Trim L3 Ear Mite Treatment 0Vaccinations stood in any that manner I assume in connection all risks. therewith I am aware as it that is thoroughly you are not under- a 24
hour care facility.
U Pain Med. U Lab 13 Other . 1.
X
130 NOT WIFIliFIE 131EILOW THIS LINE Signature ot.L'egal Owner or Authorized Person
t.,• V \
Service $
t.) •:11 I Spay/Neut $
$
.....
- II E111181)5111159{ Ill Declaw $ •
-3: 15 BAR y1:1 OTHER . VAC $
): VVKIL (SEE BELOW)/ ., .t• v (- / r--... .! Nail Trim $
AT P-DP.HEALTHy'.0 OTHER: 1 I Vet Li 1..1.0 -1C y( A. Dental $
--1 vxfp ' TNTC1 EAG Li 1 $
Recovery Status' Heat/Preg $
Weight r Ternp.ir'10 p R •ip / P Cryptorchid$
Vaccinations Given . il" Meds $
Medication Given.. Ear mite Tx $
Rx . Lab
Veterinarian Signature .
Coupons (-)
El Booster Vacs needed in 3 Weeks U Annual Vacs in 1 year Return for suture removal (10-14 days)
0 Return in 6 mo. refill heartworm med. Testing: FELV FIV Heartworm TOTAL Is _
tt7.12_Q prc rno 11:21=DI A ncri/ICK11" nrinv iG I no,- ocrnonc
15073203
RABIES VACCINATION CERTIFICATE Tag fee $:
MON
ADAPTED NASPHV FORM 51 Tag it:
Owner's Name &Address PRINT - use ball point pen or type Cert. Serial It: Nstrz
PRINT LAST FIRST MI TELEPHONE
Application for license must be made
Zoir/ '
tO ays. The term of license is based on the
NO. STREET CITY STATE ZIP
./ cv, aro n cLcio
192.-
SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS: llication, a copy of rabies vaccination
Dog („Vf Male 3 Mo. to 12 mo. E Under 20 lbs. Ai95UT Zare & Control to : Animal Care &
Cat U Female 12 Mo. or older NIA 20 - 50 lbs / ck
Other E Altered Over 50 lbs. El I NAME:
(Specify) Ce- h k only.
/Arc-ie/
DATE VACCINATED: PRODUCER:
Veterinarians !! _
6 / License No.
'
Month Day Year
(First 3 Letters)
Veterinarian's Over 1„:.1
VACCINATION EXPIRES: 1 yr. Lio.NaccX Signature 65? l.'" si 1. Yes [•": 1 2.No
3 yr. Lic./Vacc.
6 / / /6 AdOXY-AND-NEUTERIA-10 Apt It
Month Day Year School Rd., St.c 7
7342-W—India11
Phoenix, AZ 85033 Zip Code
C0410001 623 g16-979
Your Pet's Information - What is the pet's name, breed, age ? (Your veterinarian can assist you with this portion)
Pet's Name Breed
Age of Pet
(Yrs/Mnths Old) Yrs Months Micro Chip #
Sex: i.Neuterecl 2.Spayed 3.Una ltered Male [-)<1 4.Unaltered Fenlae.
ri
(Check One) TriColor
Primary Secondary
Color Black/Brown/White
Color
Your Payment Information — How much is this going to cast me? 7
indicate the Amount You're Paying
Type of Charges
License Fees:
Altered Dog (Spayed/Neutered): 17.00
111 Unaltered Dog (Male or Female): 42.00
Ej 65 Years Old or Older (Limit 2 dogs per household) $6,00 (Altered Dog Only)
Penalty/Late: Calculation Table:
$2.00 Per Month Altered Dog 2.00 X (NO OF MONTHS) =
$4.00 Per Month Unaltered Dog 4.00 X (NO OF MONTHS) =
Voluntary donation of to save more pets lives:
Your Total Cost (Enclosed Payment):
I swear or affirm that the information contained above is true and that I am 18 years old or alder and that! am owner of the dog referenced in this document:
Signature: Date:
TO BE COMPLETED BY THE VETERINARIAN ONLY
Vaccination Date Month (MM) Day (Do) Year (YYYY)
(MMDDYYYY)
Manufacturer: /, Boeh-Ingel 2. Inte rvet 3. Merial 4. Loads
(Check One) (Fort Dodge) (Pfizer)
Vaccination 171 1.0ne Year F-1: 2. Three Year
Serial / Lot 4: onsorocpc+an,ic Term:
Clinic/Hospital Clinic ID # (assigned
Name: Ltc to you by MCACC):
(Starts with "G")
Veterinarian's
Signature: a Am-Nyna.._
THIS LICENSE APPLICATION IS NOT A STAND-AWNE
p e I-, er,s ..f. 11 .5'1. Et 1^. try---2-11 ° A e,
'et Clinic, LLC
RABIES VACCINATION CERTIFICATE Tag tee s: 3hool Rd„ #108
ADAPTED NASPHV FORM 5/ Tag #: 7 85033
Owner's Name & Address PRINT - use ball point pen or type Cert. Serial it: 5-3979
PRINT LAST FIRST MI TELEPHONE
rly 6,--,3 p,7,4 /6 9-a.
/1-AZ P1-6 / f jec .me Phone:.iz
NO._,., SWEET CU- ) STATE ZIP
7—'8' i3c;‹ 775- 3 6 c od ye_cz. r '&1T .7. i.,' Day Phone:
SPECIES: SE( . .,..?„,._ SIZE: PREDOMINANT BREED: COLORS: .
Dog 4,4. Ma's 7. Mo. to 12 Mo. D Under 20 lbs. E S "tip )C . 1309 1-2d /c,
Cat LI Femae — - 2 Yd. or older 20 - 50 lbs Iii
Other 0 Altered Over 50 lbs. AbNAME: • L.A..- At / 71.e.,
(Specify) / ,2.,i/ /
Cat 0 Male 0 Female Age__
DATE VACCINATED: PRODUCER: Veterinarian's It e / 6 " S --- kllergies9
o- / ii lir License No.
Sneezing LI Appetite change
Month Day Year (First 3 Letters) Veterinarian's
1 yr. Lic./VaccF Signature ,,.0- .,, - i, , B •• • . •
VACCINATION 9._ i t , EXPIRES: i l k 3 yr. Lic.N acc. D r / Address /342W ISIdirit', 5610C1
O f- PhOefliX, AZ 85033
Day Year 6227.80,-.3979
Vacc. Serial (Lot) No.
..........4...
ukemia tested U Stray (past or present)
••',‘,ar been vaccinated?-0 Yes 0 No If Yes, in which month of this past year? Has it been over 1 year? 0 Yes 10 No
apply Dog: ID Parvo/Distemper combo LI Bordetella U Rabies (MoNear)_/
Gat: D FVRGP LI Feline Leukemia LI FIR 13 Rabies (Mo/Year) 1
at-c-Oze the following: Li SPAY (Female) 0 NEUTER (Male) LI Declaw You are to use all reasonable precautions against injury, escape,
or death of my pet, but you will not be held liable or responsible
LI)t- LI nail Trim CI Ear Mite Treatment -U Vaccinations 4?, in stood any that manner I assume in connection all risks. therewith I am aware as it that is thoroughly you are not under- a 24
hobr care (acility,
0 Ir Vet Lab 0.0ther.-- , i • r # \ -,--\----- ,, i-, v, , \ --,r, ', ,\•.- \ \-.' '' .-
X
00 rics -r AM Ft lir IE B E IL 01 AA/ -ir HI I S IL II iiI11 E Signature of Legal Owner Or Authorized Person
S BAR OTHER: _
Service $
I II . — ' S. E BELOW)
TET,1 1.11.1,11 IF Spay/Neut $
LIHY D OTHER
:
Declaw ,$
VAC
Nail Tirn $
Dental $
Recover' S'..----2._7•._=„ - Heat/Preg $
Vi e ight ' -7:..-,..,..-,, - :-... 1 :/ p / F. R Cryptorchid$
Vaccinations Mods $
Medication Gt -s -e7 ._" Ear mite Tx $
Rx- Lab
Veterinarian Signature - 1.
.0 Booster Vacs needed in 3 Wes ECS =I Return for suture removal (10-19 ys) Coupons (-)$
Li Return in 6 mo. refill hearbe‘orm Testing: FELV FIV Heartworm TOTAL
t7c.00 cc cruin ocni A 811.7. • IT t,‘ r-• • • •••• r-- i "
Owner's N.a--",
PRINTIS5g11
—MLA
Home Phone:_
_ Day Phone:
SPEL4rES - —
Dog YC.; SA**
-_-.
Cv7E-- WrI
iSpec f:
] Cat . 7.1 Male J Female Age_
Veter:rarian's ;/Allergies?
License No.
/Sneezing Li Appetite chan ge
-7 'Y! Veterinarian's"
Vim .
Signature
Address '13'12,dollanalocal_
Month Da y- 'Year Pir_Den -12(_et 2-
Vacc. Serial (Lot) No.
'AC0410001
_cukemia tested 0 Stray (past or present'
MIME
Has your pet ever been vaccinated? U Yes U No If Yes, in which month of this past year? Has it been over 1 year? Yes Li No
Check those which apply Dog: 0 Parvo/Distemper combo U Bordetella 0 Rabies (Mo/Year)
Cat: U FVRCP U Feline Leukemia r=.1 HP r0 Rabies (Mo/Year)
I hereby authorize the following: U SPAY (Female) 0 NEUTER (Male) Li Declaw You are to use all reasonable precautions against injury. escape.
or death of my pet, but you will not be held liable or responsible
Dental J Nail Trim 0 Ear Mite Treatment 0 Vaccinations in stood any that manner I assume in connection all risks. therewith I am aware as 11 that :5 thoroughly you are not under- a 2.1
hour care facility.
1.0 Pain Med. Li Lab 0 Other.
X
ID C3 1\1 11— [11 E IE IL 13 ItAir U 11-1 a_ 1 E Signature of Legal Owner or Authorized Person
BAR 0 OTHER:
0: Wis4-6-(S-E-E-BELow) Service $
A: APP.HEALTHY 0 OTHER: Spay/Neut $
Sx Vx 0 TNT 0 AG IJ
Declaw $
VAC S.
i g 12g a2.6. L; -oo Nail Trim $
-Sga7. •-• [1 70
021 g 1. 5 Dental $
Recovery Status . Heat/Preg $
Wei g ht Temp P R / P A ./ P Cryptorchid $
Vaccinations Given . Meds $
Medication Given . Ear mite Tx $
Rx. Lab
Veterinarian Signature'
Coupons Os
J Booster Vacs needed Fri 3 Weeks U Annual Vacs in 1 year i Return for suture removal (10-14 da ys)
J Return in 6 mo. refill heartworm med. Testing: FELV FIV _ . - ficartworm TOTAL_ S
Pet Clinic, LLC
RABIES VACCINATION CERTIFICATE Tag fee $: School Rd., 4108
ADAPTED NASPHV FORM 51 Tag tt: AZ 85033
Cert. Serial 4 l: 46-3979
twner's Name & Address PRINT - use ball point pen or type
'AIN 11-Nr.-.\; f.) IRS ---, 1 A Ii \
-.1A ' 1 CM a -tome Phone - -
16--- \. ) ."..,\, S .,__ \ ,a —1,, 1, 4-,-__ „.._._ Cr: , . , . .. • STATE zIpc--,,,r..... :7-_- C----3
' _), K,',:. 1•,... \ 1 ,-24. ., 7::: c„'" rt V . Day Phone:
;PECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLOR
:og .. .j Male 3 Mc. to 12 Mo. . Li Under 20 lbs. E
;., i Female E 12 Mo. or older V. /
)ther E Altered ,4 Over 50 lbs. D NAME: t L,WI\ ,K ArL.
Specify) \51;'111VrO(1\ ‘,... \ t, i . A • , ' ...,), Cat l0,Male 0 Female Age
)AT VACCI TED: PRODUCER: Veterinarian's If Allergies?
\C----) , 1 IN License No. /Sneezing U Appetite change
Month Day Year (First 3 Letters) Veterinarian' (7),,,4v .,,....f ---
1.-
1 yr. Lic.Nacc. [X, Signature _
/AGGINATIO0 EXPIRES: V
\ 4:. ..) 3 yr. Lic.Nacc. 0 , , . .C.• • s , --.e-T-cr-t. Address ....,ilixt,L.INIC
vionth , Day Year ‘ / _ It 1.-ii,i4i _. 7 V?. ill. (14:11;:..;1 :.A',0-0-FRo'7,-STFITt.rd
Vacc. Serial (Lot) No. Phoffti),',, AZ 85033
.T I , -7,,,,
5,C04 1 0001
;ukernia tested Li Stray (past or present)
Has your pet over been vaccinated? 0 Yes EU No If Yes, in which month of this past year? Has it been over 1 year? U Yes U No
Check those which apply Dog: U Parvo/Distemper combo a Bordetella r0 Rabies (Mo/Year)
Cat: 0 FVRCP 0 Feline Leukemia .0 FIP U Rabies (MoNear)
I hereby authorize the following: 0 SPAY (Female) 0 NEUTER (Male) U Declaw or You death am to of use my all pet. reasonable but you will precautions not be held against liable injury, or responsible escaae,
in any manner in connection therewith as i! is thoroughly under-
Dental Nail Trim U Ear Mite Treatment D Vaccinations stood that I assume all risks. I am aware that you are not a 2 .4
hour care facility.
LI Pain Med. Li Lab U Other . ' X
1E30 NOT WRI -FE BELMA/ —FM—IIS Signature of Legal Owner or Authorized Person
OT ,•-• ,
Service $
(SEE PyELOVvr) V--r-
Spay/Neut $
AF HEAD.: r( 0/PT - R:
ry-.:{1,17,-
Declaw $
VAC
Nail Trim $
Dental $
Heat/Preg $
Recovery Status*
p Gryptorchid $
Weight ' Temp. P R / P
Meds $
Vaccinations Given . Ear mite Tx $
Medication Given . Lab
Rx .
Veterinarian Signature: L(3--fe..44----
Coupons (-)s
Booster Vacs needed io 3 Weeks U Annual Vacs in 1 year Return for suture removal (10-14 days)
j Return in 6 mo. refill heartworm rned. Testing: FELV FIV Hrartworm._ TOTAL iS
"-snn r•••- In 19 r. nit A el,r- aPir'ilf -r f1ri 1 Or I r%e -r rlice-‘ranr-ic