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Maricopa County t9- 36a7,3 Animal Care & Control 2500 South 27°' Avenue Phoenix, AZ 85009 Phone: (602) 506-7387 pets.maricopa.gov KENNEL PERMIT PREMISE INSPECTION APPLICANT A_)ct e/fla rna STREET ADDRESS 14 1A--) e c en %PIC LIA CITY, STATE, Z11) )11_19 171..‘t ?- S5053 PHONE ALTERNATE PHONE COUNTY DISTRICT 1-k KENNEL LICENSE # NUMBER OF DOGS_1121 1. Are all dogs over the age of three months properly vaccinated for rabies and in possession of a valid rabies vaccination certificate? Yes No 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 majntains five or more dogs under controlled conditions? Yes No CORRECTIVE ACTION NEEDED FOR COMPLIANCE AND DAYS GIVEN BEFORE REUNISPECTION. (Note: There will be $49 re-inspect fee payable to the Inspector by check upon each return visit.) Deputy Enforcement Agent #1(___ Date Maricopa County Animal Care And Control 2500 South 27th Avenue Phoenix, AZ 85009 (602) 506-7387 Tele. (602) 506-2739 Fax KENNEL PERMIT APPLICATION New gl Renewal Permit # 1 C- 0,) Name: NO\ C:\ne-t,r4/VVA Kennel Name: nAct Mailing Address: 1---\ C 1 Uk...) f Cc; fverla 241 Kennel Location: Lo 1,0. -1"; f et-.1 6.ito Lrl City 0V 4 \ De p ZIP County Supervisorial District _ Home Phone: _ _ Kennel Phone: 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 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 conditions (ARS 11- 1001). 2. n C—I/We certify that I/We have /‘ dogs and that the kennel meets the definition in statute. 317 Q 1/We certify that INVe 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. C-----INVe 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. 6. yie„...-1 NVe certify that INVe 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.R.S. § 11-1008. I/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. 7.11C— 1/We 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. I/VVe 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. e--The 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. INVe certify that all of the information I/We have provided is true and accurate under penalty of law, Applicant Signature Date: ,24iy Applicant Signature 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 and Control 2500 S. 27th Avenue Phoenix, AZ 85009-6797 (602) 506-7387 http://pets.maricopa.gov Receipt Number: R14-230066 Receipt Date: 11/19/2014 Person ID: P1246031 Phone: 602 8964019 CHAPMAN KENNELS 11/1912014 12:49:33P! 4201 W TIERRA BUENA LN PHOENIX, AZ 85053 Item: Animal ID: Reference No: Price: Each: Amount: KEN PERMIT A7777777 K15-000024 $328.00 1 $328.00 Totai 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 APODACAP EBUSOFF 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 i C.hCADO10 11 AC i. 1 No. Street t , City ,•,.., State LP-01 - - i le ‘ Irck icterkok I r, Pi9ct_n, )c A-7_ -k i SC'._ Species: Sex: Age: Size: Predominant Breed: Colors: Dog % Male gi 3 ma to 12 mo 0 Under 20 lbs, (in 9 ec-k eau-A.1 Cat 0 Female 0 12 mo or older NI 20 - 50 lbs. El Other: CI Neutered CI Actual Age -7 y Over 50 lbs. CI LUIr‘i -1-e (Specify) Actual_b_lbs New: Na En 1 •e_ DATE VACCINATED: Producer: ,f) Veterinarian's: # ) I WI PC. (License No.) )0 6 0 (First 3 letters) ; 4:4,,g,se, Month Day Year (Signa ure) 0 1 yr. LIc./Vacc. Address: IA 3 yr. Lic./Vacc. VACCINATION EXPIRED: Other ni'z 5 sg i ID Month Day 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 IV) - _ No. Street City A, State Zip Li DOi ( t) —Fie_rr "A VliAt7 ri_cA. (. fa r hQC111 >( Az -FiL750t53 Species: Sex: Age: Size: Predominant Breed: Colors: Dog Male 0 3 mu to 12 mo Li Under 20 lbs. RI , , 6 taCk Cat CI Female 1X1 12 ma or older IX 20 - 50 lbs. 1:1 Other: CI Neutered IK Actual Ag e (L, V Over 50 lbs, CI CAMI‘A-e (Specify) Actual lbs Name: .. -inny DATE VACCINATED: Producer: p F T., Veterinarian's: # 1 I -g ci A2.. a,. (License Ne.) 1 0 1 1 r) (First 3 letters) 76)-p3-. ‘1.66,J.e I' Month Day Year CI 1 yr. Lic./Vacc. (Signature) Address: 3 yr. Lic./Vacc. VACCINATION EXPIRED: Other 10 14 15. S I -7 I 5 q. iC1 -1-c_ryke-e. AZ 2,f.5"ni Month Day Year Vacc, Serial (lot) no, OWNER'S COPY RABIES VACCINATION CERTIFICATE , NASPHV Form #5/ Rabies Tag Number Owner's Name and Address Print - use ball point pen or type PRINT - Last First M.I. Telephone ,-..C% i NJ CA-TILL-- ! No. treet . , City c, , ,. State oz --' Kip Species: Sex: Age: Size: Predominant Breed: Colors: Dog 'Rli Male 0 3 mo to 12 mo CI Under 20 lbs. L _..1— Cat CI Female X 12 mo or older 1:gl 20 - 50 lbs. 0 L.) ril " I ZIA c t Other: EI Neutered 0 Actual Age 5y Over 50 lbs. El LA3V-11 4t. (Specify) Actual i. lbs Name: . . DATE VACCINATED: p F Veterinarian's: # ) 12g AZ_ Producer: License No) 1 0 1 g1 1 J (First 3 letters) Month Day Year CI 1 yr. Lic./Vacc. (Signai) Address: "g 3 y r . Lic ./Vacc. VACCINATION EXPIRED: Other ID 11-4 J S1716)ZA 'T4- 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 No Street City ru State —1 Zip L4001 LAI) Tleirro, 1?-3i.,1r)ek t....r1 Species: Sex: Age: Size: Predominant Breed: Colors: Dog .jil Male 0 3 ma to 12 mo 0 Under 20 lbs.,X aeC,I Cat 0 Female lil 12 ma or older Iiil 20 - 50 lbs. 0 CZAV et I I . -C,r- Other: 0 Neutered 0 Actual Age 24 Over 50 lbs. CI (Specify) Actual.lbs Name: ArnieYe( DATE VACCINATED: Producer: p F __,—. Veterinarian's: # ) )341 AZ (,,cer,s. yo.) --1- , ri 10 15-) ID (First 3 fetters) Month Day Year 0 1 yr. Lic./Vacc. (Signature) ' 3 yr. Lic./Vacc. Address: VACCINATION EXPIRED: Other -6a5 e 04-t-s-i- ic) 11-1 .1s- Month Day Year Vacc. Serial (lot) no. nv.ii, ! Fil s ( -)FY RABIES VACCINATION CERTIFICATE NASPHV Form #51 Rabies Tag Number Owner's Name and Address Print - use ball point pen or t ype PRINT-t 4t First iv1.1. Telephone ___ Lvcity fhei.„.15st ey.A.61 s_3 . _ No. , ,, Street / _ a 0/ 0,4 ifre4A4 Species: Sex: Age: Size: Predominant Breed: Colors: Dog Male 0 3 mo to 12 mo 0 Under 20 lbs41 Ict res (..elo--" Cat Female *. 12 mo or older 20 - 50 lbs. 0 /1-64.9 / c. Other:0 Neutered 0 Actual Age / y r Over 50 lbs. CI (Specify) Actual /4/ lbs. Namen ,orretit.-6/7 DATE VACCINATED: Producer: ---) Veterinarian's: # .4-- E: (License No.) ii /1 /11 (First 3 letters) ral5Z(:)`; Month Day Year (Signature) 10 1 yr. Lic./Vacc. Address: 3 vli ° E. i 0 3 yr. Lic./Vacc. _) VACCINATION EXPIRED: Other A2-1:5--.2i) _ _IS 3/ 30 e / '7 - u _il - 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 - La_ st i First M.I. Telephone Ch6 -1...-1/1 No. i i .. _ S eet , 4, City tate 1!Zig, - 7010/ WI k/P-ViCk E --1A0,- -A-4 /04_, • . 1..) Species: Sex: Age: Size: ... _ 1 Predominant Breed: / C lors: Dog IS- Male 3 mo to 12 mo 0 ,. Under IrK 20 lbs. Cat 0 Female 12 mo or olderiS 20 - 50 lbs. • - 72.14 ..A A1F Other: 0 NeuteredJ Actual Age)), r Over 50 I . 0 QA/1 (Specify) ActuaIji . Ibs. Nam,22 , - DATE VACCINATED: Producer: 7 0 E Veterinarian's: # (License No.) ii 0.- j l'i (First 3 letters) Month Day Year 0 1 yr. Lic./Vacc. (Signature) >6 yr. Lic./Vacc. Address:3 _S . E; 15'-t/5T- VACCINATION EXPIRED: Other A.,pral Al.-i--s-4) 1L__LL- 17 1,3 014 Month Day Year Vacc. Serial (lot) no. OWNER'S COPY RABIES VACCINATION CERTIFICATE Rabies Tag Number • NASPHV Form #51 Owner's Name and Address Print - use ball point pen or type PRINT - Last First A ‘ M.I. Telephone N..../ ( 1 No. 1 Oyet t 1 le real harri Lc.04 nr_ State1 ---, Zifk5 es3 V r 0e,rii X II fr Species: Sex: Age: Size: Predominant Breed: Colors: Dog NI. Male El 3 mo to 12 mo 0 Under 20 lbs. EN ....", i T-LiA 'DV\ 1 V-, Cat El Female 1 12 mo or older N 20 - 50 lbs. 0 Other: DI Neutered Actual Age Over 50,10. D (Specify) Actual Alek lbs Nam% e C,6 oVi DATE VACCINATED: Producer: p r Veterinarian's: # License No) fl 'r I (First 3 letters) I Iq f. (Signature) ' Month Day Year I=11 yr. Lic./Vacc. Address: 213 yr. LIc./Vacc. VACCINATION EXPIRED: Other ' c45 e-- . i 641.‘ '4—' 1$ _& c.) &H1 1 •Ten-p-t_ A7-135aF I. _a_ 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 - a First NIL Telephone Aglafrj ._ No. reet , City /94,_ t a* 2, if icr3 5:). ) Cv1(1 Species: Sex: Age: Size: Predominant Breed: Colors: Dog Male CI 3 mo to 12 me 0 Under 20 lbs‘le je) Cat Female 12 moor older 74 20- 50 lbs. 0 / nt_10-rie-r (CO" Other: 0 Neutered Cil Actual Age /yr- Over 50 lbs. El (Specify) Actual /5' lbs Name: de_11z., DATE VACCINATED: Producer: i 0 .F Veterinarian's: # A 42.' I r (License No.) _ ii // / if (First 3 letters) a'1•I• 6-Yr`Cit; a0,vvely Month Day Year 1*i yr. Lic./Vacc. (Signature) 32s- F if Address: s•^7,/ Sc n 3 yr. Lic./Vacc. VACCINATION EXPIRED: Other 407—,.7W / 4Er',52-7) U a ji 3/304g -' Month Day Year I./ cc. Serial (lot) no. 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 _ U.k.OLA-I .... . . _ NI,D, Stree . State ID-- 4)0 i ()kJ . I If .1 ra g-)11,-CACA LnatY P kOf.1-1 ‘) X Species: Sex: Age: Size: Predominant Breed: Colors: Dog 54 Male 0 3 mo to 12 mop Under 20 lbs. Ikl 1 .— IC.1 Cat EI Female g 12 mo or older p 20 - 50 lbs. ID T-4\ I 11 1214 Gi', Other: 0 Neutered CI Actual Age 3y Over 50 lbs. 0 (Specify) Actual Cik lbs Name: .1-eci-776k WI DATE VACCINATED: Producer: p F .3:- Veterinarian's: # ti P1-2— (License No.) )0 1.6 I (First 3 letters) a /%,-.3-- aed_ii Month Day Year NI 1 yr. Lic./Vacc. (Signature) Address: fA 3 yr . Lic./Vacc. VACCINATION EXPIRED: Other 3)6 E 1f:0— c5f• 10 I-( 16 61 -71r)/8 A Ten, 0,4 ez_ ?5es I Month Day Year Vacc. Serial (lot) no. f - OWNER'S COPY RABIES VACCINATION CERTIFICATE NHV ASP Form #51 Rabies Tag Number Owner's Name and Address Print - use ball point pen or type PRINT - Llst First M.I. Telephone Ati. (pr..„, a. .... , . No. Steel, ,ej,•-..1 Vity k x, 40437v:Ify s.'7)--7. "MI? Species . Sex: Age: Size: Predominant Breed: Colors: Dog Male Ig] 3 mo to 12 mo El Under 20 lbs.-0 m' , ,..- 6,,, Cat El Female ID 12 mo or old rTA 20 - 50 lbs. El p../„kii Lict del 4 • Other: Neutered 0 Actual Age ‘ Over 50 lbs. El (Specify) e• Name: Actual lbs. 47CVe DATE VACCINATED: Producer: 0 Veterinarian's: # )--6 / (License No.) 1. i /1 iti (First Setters) 1.277 ,e'''.-/?7 . • : ''' 7 "e'fr.-1‘7/ Month Day Year "i‘l yr. Lic./Vacc. (Signature) 1:1 3 yr. LIc./Vacc. Address: VACCINATION EXPIRED: Other ,f7 A -x- /....52,- FLW) )) a LC 1 3/3'04)1:, Month Day Year Vacc. Serial (lot) no. "MER' S CIDPY RABIES VACCINATION CERTIFICATE Rabies Tag Number NASPHV Form #51 Owner's Name and Address Print - use ball point pen or type PRINT - Last First M.'. Telephone r max\ k_)ru-1,c_ti No. Street , , City State Zip erre.' kilo-le-A, Le% pive,nix R7._ 1.7 6.5,3 Species: Sex: Age: Size: Predominant Breed: Colors: Dog It Male % 3 mo to 12 mo 0 Under 20 lbsSei i Cat ID El Female 0 12 mo or older It 20 - 50 lbs. 0 COAia I , Other: 0 Neutered 0 Actual Age (s y Over 50 lbs. CI tiJ h 1 +e (Specify) Actual lel lbs Name: L/AnLe. DATE VACCiNATED: Veterinarian's: # 1 I 31 ai -Producer: F (License No.) 1 0 1, .1___ (First 3 fetters) OA Month Day Year 0 1 yr. Lic./Vacc. (Signatuie) A Address: 3 yr. Lic./Vacc. VACCINATION EXPIRED: 3)-6 E 164k. 54 Other tb )4 6 S 1-Mi 5? A TeAype_ A2-S ,>-'q I Month Day Year Vacc. Serial (lot) no. OWNER'S GORY RABIES VACCINATION CERTIFICATE NASPHV Form #51 Rabies Tag Number Owner's Name and Address Print - use ball point pen or type PRINT - Last First Mi. Telephone C. Marl L _ No. Street, Stak iiki:65 t--PCIt i W . -11.4erielek P-i,,..tsi_rtCt. 1_, 14-Cre_ili .K, Species: Sex: Age: Size: Predominant Breed: Colors: Dog N Male 0 3 mo to 12 mo CI Under 20 lbs.K Cat 0 Female ti: 12 mo or older jR3 20 - 50 lbs. 0 Lft I "AfAlf Lu Other: El Cl Neutered Actual Age */ Over 5.q As. • (Specify) Actual 1 6 lbs. Name; aryjd - Y-1, n2 DATE VACCINATED: Producer: f T Veterinarian's: # ycense 1 1 _i a n lot (First 3 letters) Month Day Year CI 1 yr. Lic./Vacc. (Signature) Address: 04 3 yr. Lic./Vacc. VACCINATION EXPIRED: Other I I leo ILI I Month Day Year Vacc. Serial (lot) no. OWNER'S col!,y RABIES VACCINATION CERTIFICATE NASPHV Form #51 Rabies Tag Number Owner's Name and Address Print - use bail point pen or type PRINT.- Last First M.J. Telephone C ik..)C-t-e\C-C.4 t No. Street City k State Zip ....il 1 • t i it re,.. tir . A. _A ' A4C- Alk A- '7.-- ./!".• Species: Sex: Age: Size: Predominant Breed: Colors: Dog p Male [X 3 mo to 12 mo 0 Under 20 lbs. CI '-trirr-411 1 _LaCk- Cat 0 Female 0 12 mo or old, 22 20 -50 lbs. 0 ' t`v? phrectt Other: 0 Neutered ESI Actual Age 5y Over 50 lbs. N -lox\ (Specify) Actual 1 °bibs Name: Sa.ffit_ DATE VACCINATED: Producer: p Veterinarian's: # 1 i 5.? 41 PI2- I (License No.) ID I, ID (First 3 3etters) al, 4-Lge,„rei/ Month Day Year (signature) 0 1 yr. Lic./Vacc. Address: 1:54 3 yr. Lic./Vacc. VACCINATION EXPIRED: Other 3D.6 16-41—S4- IQ_ ILI 16 ,)111c-srEll Te-rnr— PR— `37:f0g I Month Day Year Wm. Serial (lot) no. 2,1 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.1, Telephone If A • L. it I . , -, Nlo. Sheet City A, S ate .„,..., • ' LOM (4) - 7-) -e ,4" (A g'-)t,ttpx,pt V it\ocni" x, Species: Sex: Age: Size: Predominant Breed: Colors: Dog g" Male 0 3 ma to 12 mo 1:1 Under 20 lbs. Ik n Cat 0 Female ii 12 mo or older Lkr 20 - 50 lbs. CI at C-K Other: 0 Neutered CI Actual Age I y Over 50 lbs. 0 GQ111,:+e (Specify) Actual ite lbs. Name: DATE VACCINATED: Producer: I Veterinaran's: 11'81 AZ • (License No.) 1 0 _ (6 0 (First 0 letters) frTilf.4"t4(7 Month Day Year (Slgnature) A -6-' CI 1 yr. Lic./Vacc. (4 3 yr. Lic./Vacc. Address VACCINATION EXPIRED: Other I 0 P-I 6 11151A -krylt, Pa_ '35d-0) Month Day Year Vacc. Serial (lot) no. OWNER'S COPY RABIES VACCINATION CERTIFICATE NASPHV Form #51 Rabies Tag Number Owners.Name and Address Print - use ball point pen or type First M.I. Telephone City State A.0 • ""17 Species: Sex: Age: Size: Predominant Breed: Dog Male gr 3 mo to 12 mo 0 Under 20 lbs. Y-.Ar CAN:Ar1.4', 5 Cat El Female 0 12 mo or older 20 - 50 lbs. 0 Other: 0 Neutered 0 Actual Age Over 501 J. El (Specify) Actual lbs DATE VACCINATED: Producer: IL (First 3 letters) Month Day Year 0 1 yr. Lic./Vacc. X 3 yr. Lic./Vacc. VACCINATION EXPIRED: F_ I Other 11_ 1c) Ito 41 Tole, a rbin Month Day Year Vacc. Serial (lot) no. OWNER'S COPY RABIES VACCINATION CERTIFICATE Rabies Tag Number NASPHV Form #51 Owner's Name and Address Print - use bait point pen or type PRINT - Last First M.I. Telephone . - --, rftLr\ ..... 2 Stakz— ,7vai36.5 zi No. Liao i td6 it .1 e.ie-mt bajo-ct Lri4 Pbot-n_A y Species: Sex: Age: Size: Predominant Breed: Colors' Dog pil Male INI 3 mo to 12 ma 0 Under 20 lbs. )4 61.01 OharLES _ Cat CI Female 0 12 mo or older tZi 20 - 50 lbs. 0 ' C906-ti-ec Other; CI Neutered 0 Actual Age I ki Over 501129. 0 (Specify) I Actual l_V_Ibs. Name: Coecti DATE VACCINATED: Producer: f Veterinarian's: .„--/ # (L cm 11'39 ND.) ft2 1\ tti 6 (First 3 letters) /07L-'-' 0./, " aKii; Month Day Year 0 1 yr. Lic./Vacc. (Signature) Address: IX 3 yr. Lic./Vacc. VACCINATION EXPIRED; EXPIRED: Other it lb 10 Month Day Year Vacc. Serial (lot) no.