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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 APPLICATION
X New LII Renewal Permit #
Name:GREGG:E aw-EA) l'kjEf44OR-A36( Kennel Name: Ams-rele's kre-Ai (OE L, S
Mailing Address: 7309' 6": 1 14 41 -14" St Kennel Location: 6L-;
City G, , AZ ZIP KS-2 9 7 County Supervisorial District
Home Phone: Kennel Phone: 171 ec) - 3 (,:' `)/
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 "operating a kennel" must obtain a permit issued
by the Board of Supervisors where the kennel is located except if each individual dog is licensed. A.R.S. § 11-
1009 and MC Ordinance No. 13, Sec. 4. define a "kennel" 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 require individual licensing of each dog under the provisions of ARS
11-1008.
PLEASE ANSWER THE FOLLOWING QUESTIONS
Initial Each
1. *AV 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. tiAl INVe certify that the kennel has been approved by the local zoning authority (if applicable) at the
premises for which I/we are making application for a permit.
3.4t613— I/We certify that INVe have dogs and that the kennel meets the definition in statute.
4. 4/114.( I/We certify that I/We have not been convicted of a violation of A.R.S. §§ 13-2910 (cruelty to animals)
or 13-2910.01 (dog fighting), or any other state, county or municipal animal welfare law. (Violations of license
and leash laws DO NOT apply.)
5./M0,1 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
maintained on the premises for each dog.
7.,IMIL I/We understand that a dog remaining within the kennel is not required to be licensed individually under
ARS 11-1008. I/we also understand that a dog leaving the controlled kennel conditions shall be licensed under
ARS 11-1008 except if the dog is only being transported to another kennel which has a permit issued under this
section.
8. 41AL INVe understand that a person who fails to obtain a kennel permit under ARS 11-1009 is subject to a
penalty of twenty-five dollars in addition to the annual fee.
6.4/101- I /We certify that INVe are submitting a valid copy of the rabies vaccination certificate for each
dog; with this application.
9.2004 I/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.
10..00 Is this kennel permit being obtained for the purposes of operating a business including but not limited to
breeders, groomers or boarding establishments? (Please check one) ti4YES 0 NO
If the answer is "YES", you will need to provide proof of lawful presence in the United States in order to obtain a
kennel permit for the purposes of operating a business. The forms of identification accepted for this purpose
are listed below.
A.R.S. § 41-1080(A) provides:
After September 30, 2008, an agency or political subdivision of this state shall not issue a license to an
individual if the individual does not present any of the following documents to the agency or political
subdivision indicating that the individual's presence in the United States is authorized under federal law:
1. An Arizona driver license issued after 1996 or an Arizona non-operating identification
license.
2. A driver license issued by a state that verifies lawful presence in the United States.
3. A birth certificate or delayed birth certificate issued in any state, territory or
possession of the United States.
4. A United State certificate of birth abroad.
5. A United States passport.
6. A foreign passport with a United States visa.
7. An i-94 form with a photograph.
8. A United States citizenship and immigration services employment authorization
document or refugee travel document.
9. A United States certificate of naturalization.
10. A United States certificate of citizenship.
11. A tribal certificate of Indian blood.
12. A tribal or bureau of Indian affairs affidavit of birth.
Please submit a photocopy of both the front and back of your identification with your completed
application. Please also be prepared to present your identification at the time of inspection by the field
services officer.
If the answer to question 10. above is "NO" please answer question 11.
11.4t0L—INVe certify that the kennel permit is being used solely for the purpose of licensing my own multiple
companion dogs in my household.
INVe certify that all of the information I/We)five provided is true and accurate un er pe aity of law.
Applicant Signature Date:
Applicant Signatur 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
Maricopa County
414 lEcc7
Animal Care & Control
2500 South 27th Avenue
Phoenix, AZ 85009
Phone: (602) 506-7387
pets.maricopa.gov
KENNEL PERMIT PREMISE INSPECTION
APPLICANT af- ec:1 (\crk.e to Mey C kof )0
STREET ADDRESS 11 1 4L'
CITY, STATE, ZIP G-; A
PHONE LW- ctn. '36 Lk -1 ALTERNATE PHONE
COUNTY DISTRICT KENNEL LICENSE # 11\15-0612 NUMBER OF DOGS
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 maintains five or more dogs under controlled conditions?
Yes No
CORRECTIVE ACTION NEEDED FOR COMPLIANCE AND DAYS GIVEN
BEFORE REINSPECTION. (Note: There will be $49 re-inspect fee payable to the Inspector by
check upon each return visit.)
Deputy Enforcement Agent Date
Maricopa County Animal Care and Control
2500 S. 27th Avenue
Phoenix, AZ 85009-6797
(602) 506-7387
http://pets.maricopa.gov
Receipt Number: R14-128589 Receipt Date: 06/30/2014
Person ID: P2269946
Phone: 480 9173647
MASTER'S KENNELS 6/30/2014 2:52:12PM
17309 S 144TH ST
GILBERT, AZ 85297
Item: Animal ID: Reference No: Price: Each: Amount:
KEN PERMIT A7777777 K15-000056 $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: Animai# Vacc Date: Vacc Expires:
Please retain this receipt with your pet's records
reyesa EBUSOFF
VACCINATION CERTIFICATE
• Official Proof of Vaccination
Keep this record in a safe place. Duplicate requests $10. Corporate Office Hours:
Value PE'T Care Mon - Fri 9:00 am - 5:00 pm
www.VaIuePetCare.co m P.O. Box 6221 • Mesa, AZ 85216
Veterinary Services & Supplies, LLC 480-656-7837 • 888-502-PETS (7387)
PET OWNER: Fill out sections #1-3 OFFICIAL RECORD - PLEASE PRINT CLEARLY
Last Name:' V, MIMI Allianilla I I i 7rs rstt
Address: 1111PV1111111111 11111111i H.
City; mil-i,t1/111-111H111111111111"-7—' Zip:
r • • 11111111111ILLJ 1 I
[
Home: L Work: (
I acknowledge having read and I understand the back of this document. Being aware of these
facts, I give my permission to VALUE PET CARE VETERINARY SERVICES & SUPPLIES, LLC DATE: /
and/or Die Doctor to treat and/or administer the vaccinations listed below.
o New Client'o Existing Client Did you get a reminder card in the mail? 0 Yes 0 No There is a $1 -$3 waste disposal fee per animal. Prescription ONLY fee $10.
10 How did you hear about this clinic? 0 Flyer from Store CI Promotional Mailer 0 Nev spaper 0 Referral 0 TV 0 Radio 0 Website CI Drive By 0 Other I
PET #1 PET #2
0 Dog El Ferret 0 .Male 0 Spay/Neul 0 Pregnant fi Dog 3 Ferret u Male -- /Neut n Pregnant
CI Cat . 71 Other 0 Female 0 On Medication CD Cat n 01 ., r .,--. Ettfemale , i CI On dication
Name: A . /I }."-=2 Z 0 Wks Name: . ...e/ e'..,0/ (1,7 n Wks
Breed: CT; 4/ / (. 3 /'-'y' Age:[ i s, 1 0 Mos Breed: ,,,/ 7 . . . , ,e,. / .P., Age:I . , I ID MOS
Colors: ,"--"' i , / •" ) -". ': - - 0 Yrs Colors: 27 -'1", ID Yrs
FOR OFFICE USE ONLY - • LEASE DO NOT WRITE BELOW THIS LINE
Rabies Type: KILLED VIRUS Mfg. LJIfIiii PRICE NEWT BOOSTERS Rabies Type: KILLEDVIRUS Mfg. [i ; PRICE NEXT BOOSTERS
Lot # , -‘ . - - Tag # -,. -------, P"sn't In'j"d AIR " " Lot /I , i / . .; 7 • ! •- Tag # ,,,,,„, pnceol (Does Bol boosters.) kleude Weeks 3-4 Months 6 Months 12 Months 38
Date Vaccinated: / P.a•armdo.4....4.1 / . PlICOOLboosiers. Vi:- Months Monins \ Rabies Dale Vaccinate • ' • . , ._,. c
Fi*.f)i
Rabies Vaccination Due: __/ . Rabies Vaccination D e: ', / • 1- c / ir I ' I
A DA2Ppv 1 DA2PPv+L / Corona 19.'1 '1 ), -.DA2PPV -/ DA2P I cl
Bordetella - Nasal / Injectable ' Bordetella - Nasal / Injectable
Lyme l Giardia / Rattle Snake Lyme / Giardia / Rattle Snake .
Deworminq (Protal 50 mg/ml) cc Deworminq (Protal 50 mg/ml) cc ,
Cat 4-in-1 (FVRCP) I Leukemia / FIP Cat 4-in-1 (FVRCID) I Leukemia! FIP
Heartworm I 3DX i 40X Test 0 Pen 0 •g Heartworm / 3DX / 40X Test 0 Pen 0 Neg
Rx Heartworm: Rx Heartworm:
Feline Leukemia! FIV Test o Pos Neg Feline Leukemia! FIV Test 0 Pos a Neg
Parvo / Giardia Test 0 Po o Neg Parvo / Giardia Test 0 Pas 0 Neq -
Flea! Tick Control: , Flea! Tick Control: 1
Micro Chip Mfg. # Micro Chip Mfg. #
Other: Qty. Other: Qty.
Other: Qty. Other: Qty.
Other: Qty. Other: Qty.
Other: Qty. Other: Qty.
Blood! IDEXX Lab F -es: Blood / IDEX)( Lab Fees:
Treatment Fee: $5 $10 $15 $20 $25 Treatment Fee: $5 $10 $15 $20 $25
Exam Fee: $5' 0 Health Certificate $25 i',-;— Exam Fee: 5 $20 Health Certificate $25
Waste Dispos. Fee: $11 $2 $3 41 — 1.. ,7 Waste Disposal Fee: $1 $2 $3
HR : , r •sp: ; NEXT BOOSTER DUE ON: 0 1,..,) 4 0 ,16) / / .., HR: / Resp: NEXT BOOSTER DUE ON c l 7721/1„_J I (, , I /
,,, . ., , ' ' ,, , I c
Temp: i • ,, ' Welght:'(±_i_ !if.; ,c. ),. 1 NOTES/DOSAGE Temp: 1 ' i 1 liVelghl: , • . , NOTES/DOSAGE
P SICAL EXAM: vJ ki fi PHYSICAL EXAM:
Shaisd Linable bCheek ChdtedUnt410 0,d,
Gen. App. 0 0 Gen. App. 0 Cl
Skirt 0 Skin 6 a
Eyes ? o Eyes o
Ears ? 9 0 Ears o
Moat P 0 Mouth Il 0
HEALTH WITHIN NORMAL LIMITS HEALTH WITHIN NORMAL LIMITS
Yes 0" _ . No 0 Yes O . No El
Veterinarian: C Store # Location: .! Tech,
State Lic # Date: i I Payment: • , Exp: Code: TOTAL, ft7
While: VALUE PET CARE VETERINARY SERVICES & SUPPLIES, LLC Yellow; CLIENT/ COUNTY
.GILBERT VETERINARY HOSP. Client No. 9787
1655 SOUTH GILBERT ROAD Hornby, Gregg & Meyer, Arleen
17309 S. 144Th St.
Gilbert, AZ 85295 Gilbert, AZ 85296
Phone: (480) 963-1815 Phone: (480) 917-3647
(480) 963-1811
Rabies Vaccination Certificate
NAME: Magic
SPECIES: Canine WEIGHT: 66.40 lbs Rabies Tag # 026853
BREED: Labrador Retriever ID #1 425D1B0044
GENDER: FS ID #2
COLOR: Black Last Visit 511912014
BIRTHDAY: 11/6/2001
AGE: 12 yrs, 6 months
Item Description ten Due Date Lot # Manufacturer Exp. Date
2007 RABIES K9 3 YRS /19/2014 5/3/2017 S305798D Pfizer Defenzor 3 2/28/2015
I hereby certify that this animal has been vaccinated in accordance with the manufacturers recommendation for the vaccine used on above date.
Dr- 71.36VeAr1(11 Sco# i2 -4ko,?-- Date Issued 6/19/2014
Dr. Scott
(9,
• GILBERT VETERINARY HOSP. Client No. 9787
1655 SOUTH GILBERT ROAD Hornby, Gregg & Meyer, Arleen
17309 S. 144Th St.
Gilbert, AZ 85295 Gilbert, AZ 85296
Phone: (480) 963-1815 Phone: (480) 917-3647
Fax: (480) 963-1811
Rabies Vaccination Certificate
NAME: Bit
SPECIES: Canine WEIGHT: 71.00 lbs Rabies Tag # 025479
BREED: Golden Retriever ID #1
GENDER: Fl ID #2
COLOR: Gold Last Visit 3/27/2013
BIRTHDAY: 6/3012005
AGE: 7 yrs, 8 months
Item Description Given Due Date Lot # Manufacturer Exp. Date
2007 RABIES 1(9 3 YRS 3/27/2013 3/11/2016 82845720 Pfizer Defensor 3 2/11/2014
I hereby certify that this animal has been vaccinated in accordance with the manufacturer's recommendation for the vaccine used on above date.
/a4/1- Date Issued 3/27/2013
Dr. Beverly J. Scott License; M63
Durant Animal Hospital
86 W Mulberry St,
Durant, OK 74701
(580) 924-1640
Rabies Certificate
10/7/2013
Name: Mark Edwards Pet's name Rebel
Address: Species: Canine
Breed: Retriever, Golden
City: Sex: Male
State: Color: gold
Postal Code: Birth Date: 4/7/2006
Rabies Vaccination Information
Tag Number 22594 Vaccination Date 10/7/2013
Lot Number D12153C Expiration Date 10/7/2014
Producer BOEHRINGER INGELHEIM
K /MVL Rabvac 3 (killed virus)
Microchip ID Number:
Vaccination Reminders:
RABIES CANINE 1 10/7/2014
YEAR
CHLP2 - Booster 10/7/2014
Vaccination
Vonlimenz.
01112,1i. IMMO" fri¢fd Mills - Owner
C I
Oc2/2
WOLF RIVER VETERINARY CLINIC
New London WI
(920) 982-2733
Client : Tom Zoeliner
Phone
Patient : Red Acct No. : 5501 G
Species : Canine Breed : Lab
Sex :F Color : Red
DOB : 06/23/2008
RABIES VACCINATION INFORMATION
Rabies Rabdonnun Tag No. 121972
Date Vaccinated 09/05/2012 Expires 09/05/2015
Serial No. S176535A Producer Schering-Plough
Vaccine Type Killed Duration 3 Years
I hereby certify that I have vaccinated this animal in accordance with the company's
recommendation for the vaccine used on the above date.
( r. ,(.(7)1 , / .1().
Signature of licepthed veterinarian administering vaccine.
James E Ziegler
3071-050
GILBERT VETERINARY HOSP. Client No. 9787
1655 SOUTH GILBERT ROAD Hornby, Gregg & Meyer, Arleen
17309 S. 144Th St.
Gilbert, AZ 85295 Gilbert, AZ 85296
Phone: (480) 963-1815 Phone: (480) 917-3647
Fax: (480) 963-1811
Rabies Vaccination Certificate
NAME: Trooper
SPECIES: Canine WEIGHT: 82.20 lbs Rabies Tag # 026766
BREED: Labrador Retriever ID #1
GENDER: MI ID #2
COLOR: Red Last Visit 4/2512014
BIRTHDAY: 9/14/2004
AGE: 9 yrs, 7 months
Item Description Given Due pate ot It Manufacturer Exp. Date
2007 RABIES K9 3 YRS 4/25/2014 4/9/2017 S) 0579 Pfizer Defensor 3 12/23/2014
I hereby certify that this animal has been vaccinated in accordance with the manufacturer's recommendation for the vaccine used on above date.
13o/-ex Date Issued 4/2512014
Dr. Scott
GILBERT VETERINARY HOSP. Client No. 9787
Hornby, Gregg & Meyer, Arleen
1655 SOUTH GILBERT ROAD 17309 S. 144Th St.
Gilbert, AZ 85295 Gilbert, AZ 85296
Phone: (480) 963-1815 Phone: (480) 917-3647
Fax: (480) 963-1811
Vaccination Certificate
NAME: Honey
SPECIES: Canine WEIGHT: 29.40 lbs Rabies Tag # 025632
BREED: Golden Retriever ID #1
GENDER: Fl ID #2
COLOR: Red Last Visit 11/4/2013
BIRTHDAY: 7/17/2013
AGE: 15 weeks, 5 days
Description Given Due Date Lot # Manufacturer Exp. Date
Item
2001 DA2PP ANNUAL /1/4/2013 10/30/2014 025842 10/30/2014
2006 RABIES K9 INITIAL 11/4/2013 10/30/2014 5287241J Pfizer Defensor 3 4/8/2014
hereby certify that this animal has been vaccinated in accordance with the manufacturer's recommendation for the vaccine used on above date.
Date Issued 1114/2013
Dr. Bode
Durant Animal Hospital
86 W Mulberry St.
Durant, OK 74701
(580) 924-1640
Rabies Certificate
10/7/2013
Name: Mark Edwards Pet's name Reba
Address: Species: Canine
Breed: Retriever, Golden
City: Sex: Female
State: Colon gold
Postal Code: Birth Date: 4/23/2012
Rab:es Vaccination Information
ti=_ber 22595 Vaccination Date 10/7/2013
D12153C Expiration Date 10/7/2014
BOEHR1NGER 1NGELHEIM
Rabi.ac 3 (killed virus)
idics04113
Vimelmor Ilterriers_
11110111131 CAINE 1 1W7l2014
WAR
MUM - ilbserisr 1W712014
Certificate Number; 3 Date Created: Jun 10, 2013
Responi We Party
Jed Packer
Patient Information
Patient: Firemark's Bridgerland Wildfire ("Bridger')
Species: CANINE
Breed: GOLDEN RETRIEVER
Weight: 60.7 lbs.
Color: GOLD
Sex:
Microchip Number: 4A1 128761B
DATE PERFORMED DATE DUE
RABIES VACCINATION Dec 23, 2011 Dec 19, 2014
PARVO-DISTEMPER Dec 21, 2012 Dec 20, 2013
BORDETELLA BOOSTER Oct 09, 2012 Apr 09, 2013*
INTESTINAL PARASITE CONTROL Dec 21, 2012 Dec 20, 2013
COMPLETE BLOOD COUNT
CHEMISTRY PANEL
HEARTINORM TEST
HEARTWORM PREVENTATIVE Oct 09, 2012 Oct 09, 2013
DENTAL CLEANING
THYROID 14 & FREE T4 TEST
PARVO-DISTEMPER TITER TEST
PHENOBARB LEVELS TEST
EARLY RENAL DISEASE TEST
FRUCTOSAMINE LEVEL TEST
BLOOD GLUCOSE CURVE TEST
PERIODONTAL DISEASE TEST
RATTLESNAKE VACCINATION
CANINE INFLUENZA VACCINATION
RABIES INFORMATION: Date Given: Dec 23, 2011
Tag Number:
Serial 1215348A
Duration: 3 Year
Vaccine Type: KV
Vaccine Name: RABVAC 3 IF
Producer: Fort Dodge Animal Health
I hereby certify that I have examined the above described animal on Dec 21, 2012 and find the
information stated above to be correct:
crimm-t (2-00
James Israelsen D.V.M.
Mountain View Veterinary Health Center
1702 N. 800 East
North Logan, UT 84341
V titRI NARY 1 lEALTIt C TC1Z. 035) 752-8251
Durant Animal Hospital
86 W Mulberry St.
Durant , OK 74701
(580) 924-1640
Rabies Certificate
10/7/2013
Name: Mark Edwards Pet's name Snake
Address: Species: Canine
Breed: Retriever, Golden
City: Sex: Male
State: Color: gold
Postal Code: Birth Date: 4/23/2012
itabics Vaccination information
Tag Number 22593 Vaccination Date 10/7/2013
Lot 'Nutubor D12153C Expiration Date 10/7/2014
Producer BOEHRINGER INGELHEIM
K NEVI Rabvae 3 (killed virus)
Microchip ED Number:
Vaccination Reminders:
Bordatella 10/7/2014
Vaccination
RABIES CANINE 1 10/7/2014
YEAR
DHLP2 - Booster 10/7/2014
Vaccinabon
GILBERT VETERINARY HOSP. Client No. 9787
Hornby, Gregg & Meyer, Arleen
1685 SOUTH GILBERT ROAD 17309 S. 144Th St.
Gilbert, AZ 85295 Gilbert, AZ 85296
Phpne: (480) 963-1815 Phone: (480) 917-3647
Fax: (480) 963-1811
Rabies Vaccination Certificate
NAME: Luna
SPECIES: Canine WEIGHT: 18.00 lbs Rabies Tag # 025633
BREED: Golden Retriever ID 01
GENDER: Fl ID #2
COLOR: Red Last Visit 11/6/2013
BIRTHDAY: 7/17/2013
AGE: 16 weeks, 0 days
Item Description Given Due Date Lot # Manufacturer Exp. Date
2006 RABIES 1(9 INITIAL 11/6/2013 11/1/2014 S287241J Pfizer Defensor 3 4/8/2014
I hereby certify that this animal has been vaccinated in accordance with the manufacturer's recommendation for the vaccine used on above date.
Date Issued 11/612013
Dr. Bode
GILBERT VETERINARY HOSP. Client No. 9787
Hornby, Gregg & Meyer, Arleen
1655 SOUTH GILBERT ROAD 17309 S. 144Th St.
Gilbert, AZ 85295 Gilbert, AZ 85296
Phpne: (480) 963-1815 Phone: (480) 917-3647
Fax: (480) 963-1811
Rabies Vaccination Certificate
NAME: Ozzy
SPECIES: Canine WEIGHT: 20.60 lbs Rabies Tag # 025663
BREED: Golden Retriever ID#1
GENDER: MI ID #2
COLOR: Red Last Visit 11/612013
BIRTHDAY: 7/17/2013
AGE: 16 weeks, 0 days
Item Description Given Due Date Lot # Manufacturer Exp. Date
2006 RABIES 10 INITIAL 11/6/2013 11/1/2014 S287241J Pfizer Defensor 3 4/8/2014
I hereby certify that this animal has been vaccinated In accordance with the manufacturer's recommendation for the vaccine used on above date.
Date Issued 11/6/2013
Dr. Bode