BUCKEYE ANIMAL RESCUE & KENNEL.PDF

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 LI Renewal Permit V1/47- 1) 131A
/ , in AA-06\1.e. OR; Nil eti ilei.-_-.501,ce kelinti
Name: I-, .4-1 a Kennel Name:
Mailing Address: 1 9 / 9 Al -200 1 a U./IV/Kennel Location: I °I. C1 AL .2)--CeeA OLg11.0
City (k-' 61: 0-ke , Az zip 6,3 9 ip County Supervisorial District
Home Phone: (.0Z 3 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 "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. Qit..) 1 IANe assume complete responsibility for the kennel at the premises for which I/we are making
application for a permit and understand that "kennel'' means an enclosed, controlled area, inaccessible to
other animals, in which a person keeps, harbors or maintains five or more dogs under controlled conditions
(ARS 11-1001).
2. I/We certify that the kennel has been approved by the local zoning authority (if applicable) at the
prer9ises for which I/we are making application for a permit.
I/We certify that INVe have dogs and that the kennel meets the definition in statute.
4. qu) INVe 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 any other state, county or municipal animal welfare law. (Violations of license
an ash laws DO NOT apply.)
5. \..f) 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. INVe understand that a dog remaining within the kennel is not required to be licensed individually under
AR 1-1008. 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.
r ‘
8. I/We 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.
I /We certify that INVe are submitting a valid copy of the rabies vaccination certificate for each
ilyth this application.
9. INVe understand that a person who knowingly fails to obtain a kennel permit within thirty days after written
noti cation from the county enforcement agent is guilty of a class 2 misdemeanor.
10. Vi 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) 14 YES 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. I/We 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 e hav provided is true and accurate under penalty of law.
Applicant Signature Date: / • ;ON
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

Maticopa County
Animal Care & Control Avv,so
2500 South 271h Avenue
Phoenix, AZ 85009
Phone: (602) 506-7387
pets.maricopa.gov
KENNEL PERMIT PREMISE INSPECTION
APPLICANT eA Oltic \l•Noi.
STREET ADDRESS fltcl aocifr'nAtyert ivi
CITY, STATE, ZIP tvkc_t,(re ,
u
HOME PHONE L,2 -d,() • BUSINESS PHONE
COUNTY DISTRICT 1.--\ KENNEL LICENSE AK- 094 NUMBER OF DOGS a 7
I. Are all dogs over the age of three months properly vaccinated for rabies and in possession of a
valid rabies vaccination certificate?
Yes No
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 Date6 ly

Maricopa County Animal Care and Control
2500 S. 27th Avenue
Phoenix, AZ 85009-6797
(602) 506-7387
http://bets.maricopa.dov
Receipt Number: R14-115970 Receipt Date: 06/11/2014
Person ID: P2262784
Phone: 623 8263085
BUCKEYE ANIMAL RESCUE KENNELS 6/11/2014 10:25:11AM
1919 N 200TH AVE
BUCKEYE, AZ 85396
Item: Animal ID: Reference No: Price: Each: Amount:
KEN PERMIT $328.00 1 $328.00
Total Fees Due: $328.00
Payments: Cash: $328.00
Check: $0.00
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.
luffmanm EBUSOFF

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35260 -Nvv.t1
12 ' 0 0 12 L0 0 0 o 0 0
Name
411) -C"-A VIRUS FELINE FELINE FELINE FELINE FELINE FELINE CANINE CANINE CANINE CANINE CANINE CANINE LYME 'RABIES VACCINATION
LEPTOSPIROSIS
Ingelheim Boehringer LEUKEMIA DISEASE
CHLAMYDIA CALICIVIRUS RHINOTRACHEITIS PANLEUKOPENIA BORDETELLA CORONAVIRUS PARVOVIRUS ADENOVIRUS PARAINFLUENZA DISTEMPER RECORD
IMMUNODEFICIENCY
VIRUS 2

VACCINATION RECORD
RABIES VACCINATION CERTIFICATE Tag fee $: Name
ADAPTED NASPHV FORM 51 Tag #: LI RABIES
Owner's Name &Address PRINT - use bail point pen or type Cert. Serial #:
-k2') D LYME DISEASE
PRINT U FIRST , MI TELEPHONEle, 0 CANINE DISTEMPER
/ ey--, i gue eySTATEdfz ee:39 62 111 CANINE PARAINFLUENZA
No/9 "FET i-XL-altr ZIP
CI CANINE ADENOVIRUS 2
SPECIES: SEX: AGE: SIZE: PREDOM NANTIEF V p: C104.7 CI CANINE PARVOVIRUS
Dog X Male 0 3 Mo. to 12 Mo. 1 I Under 20 lbs. , ,Iii ,, 0 CANINE CORONAVIRUS
Female V 12 Mo. or older kit) 20 - 50 lbs A-- 6Iit e a I It 0 CANINE BORDETELLA
( ,. E] ° Altered LI Over 50 lbs. El NAME: 0 LEPTOSPIROSIS
(Specify) ryi 0, ri 0 1 Ef O FELINE LEUKEMIA VIRUS
CI FELINE PANLEUKOPENIA .
DATE VACCINATED: PRODUCER: Veterinarian's #
NM Lice e N / CI] FELINE RHINOTRACHEITIS
i(0' G\ i ti 0 FELINE CALICI VIRUS
Month Day Year (Ft at 3 Letters) Veterinarian's
n FELINE CHLAMYDIA
1 yr. Lic.Nacc.N Signature El FELINE IMMUNODEFICIENCY
VACCINATION EXPIRES:
3 yr. Lic.Nacc. t_ - -r., Address VIRUS
lap t2aw
Month Day Year
Vacc. Serial (Lot) NO.- (7"\ I Boehringer
__\ /I e MI) Ingelheim
VAC0410001

Month I Month ) DATE (Specify) Other Cat Dog Dog SPECIES: Niel Owner's
VAC0410001 il VACCINATION 2. 0 0 0 1 PRINeaa '
i q Name
Day 40 Day VACCINATED: &
/ EXPIRES: / ( Altered Female Male SEX: STINT, Address
Year -ear -.'
3y 1 yr. 0 X
. PRODUCER: 12 3 AGE: aof,4 FIRST
Lic.Nacc. Mo. Mo.
12 Lic.Nacc.- or to 0 RABIES
0 older 12 (t_
Vacc. (First II Mo. tom
3 PRINT ADAPTED
Serial i rill X. 0 -
`-.1-11 Letters) 20 d use VACCINATION
(Cot) Over - Under SIZE: ball
No. 3 50 50 20 ettoiayt point NASPHV
r) lbs. lbs
ieri lbs. geouce pen
0 0 E or FORM
s type
Address Signature ill NAME: 51 CERTIFICATE
Veterinarian' Veterinarian's t MI
i STATE
i -;
,... 1 PI''. c.., License C) BFell4 ,
0 ZIP Cert. Tag Tag
, COLORS: e Map- TELEPHONE #: fee
Serial $:
3 , I 5,-3 #:
I • 9 3M3.5 Lizz .
5" Le
0 0 O 0 0 0 o 0 0 0 0 0
Name
411llgi VIRUS FELINE FELINE FELINE FELINE FELINE FELINE CANINE CANINE CANINE CANINE CANINE CANINE LYME ARABIES VACCINATION
LEPTOSPIROSIS
Ingelheim Boehringer DISEASE
CHLAMYDIA CAUCIVIRUS LEUKEMIA BORDETELLA CORONAVIRUS PARVOVIRUS ADENOVIRUS DISTEMPER
FiHINOTRACHEITIS PANLEUKOPENIA PARA1NFLUENZA RECORD
IMMUNODEFICIENM
VIRUS 2

MILL CREEK VETERINARY Client No. 11639
HOSPITAL RODRIGUEZ, SARAH & AARON
6212 131ST PL. SE
15704 MILL CREEK BLVD. #16 EVERETT, WA 98208
Mill Creek, WA 98012 Phone: (425)
Phone: (425) 745-9733
Fax: (425) 316-3405
wvvw.milloreekveterinary.com
Vaccination Certificate
NAME: L
SPECIES: CANINE WEIGHT: 69.00 lbs Rabies Tag # 13226
BREED: PIT BULL ID #1
GENDER: Fl ID #2
COLOR: RED/WHITE Last Visit 3/4/2014
BIRTHDAY: 10/1/2010
AGE: 3 yrs, 6 months
Item Description Given Due-Ba--- „\ ------,Lot Manufacturer Exp. Date
0201 RABIES 3 YR 3/9/2013 3/3/2016 /S285955K P Fl 'LER
0207 DHLPP ANNUAL 3/4/2014 2/27/2 MERIAL
I hereby certify that this animal has been vaccinated in accordance with the manufacturers recommendation for the vaccine used on above date.
)/44 6e1-
k04 Date Issued 412212014
Dr_ Betts License: 1944

ATBC - Phx
602-943-7729
Animal Summary / Rabies Summary
This is not an invoice.
Owner
B.A.R.K.
1919 North 200th Ave, Buckeye, AZ 85396
623-826-3085
Animal Details Animal's Name: Morelli
Sex: Male
Species: Dog
Age: 0.00 Years, 9.0 Months
Color: Grey!
Breed: Poodle (Miniature)
Weight: 10.24 lbs
Visit Date: 5/27/2014
Animal Number: 14-4910
Microchip Number:
Rabies Vaccine Producer: Boehringer lngelnelm
Type: One Year
Vaccine Lot.Number: 1215388A (expires 6/6/2015)
Date Vaccinated: 5/27/2014
Expires: 5/27/2015
Veterinarian: Kellie Ayle, License #
Signature: L
Clinic Info: ATBC - Phx
950 West Hatcher Road, PHOENIX, AZ 85021
602-943-7729
All Products/Services Date Description
5/27/2014 Dog Neuter
5/27/2014 Rabies 1 year vaccine
This is not an invoice.

VACCINATION RECORD
RABIES VACCINATION CERTIFICATE Tag tea $:
Name
ADAPTED NASPHV FORM 51 Tag #:
Owner's Name &Address PRINT - use ban point pen or type Cert. Serial it: 141ABIES
/0 1,6dale 0 LYME DISEASE
—'NT 6"tektiVIRSTAiutrnai TELEPHOE, 4. 2 2-_6___
o CANINE DISTEMPER
Ow v,./e F7-40 ' i-3el iZ5
NO. 1 9 / /REEF Ai, 70 ph STATE 2563 940 D CANINE PARAINFLUENZA
0 CANINE ADENOVIRUS 2
SPECIES: SEX: AGE: SIZE: PREDD INANT BREED: COLOp:149 D CANINE PARVOVIRUS
Dog )4) Maio g 3 Mo. to 12 Mo. 0 Under 20 lbs. Sk, - /11124 el 0 CANINE CORONAVIRUS
Cat 0 Female 0 12 Mo. or older -4i:l 20- 50 ibs ID D CANINE BORDETELLA
Other o Altered V Over 50 lbs. "Til NA :
LI LEPTOSPIROSIS
(Specify) nil Oh #
D FELINE LEUKEMIA VIRUS
DATE VACCINATED: PRODUCES: 0 :' 0 FELINE PANLEUKOPENIA
Veterinarian's / */
SINN D FELINE RHINOTRACHEITIS
6\ i I' /
Month Day Year (First 3 Letters) FELINE CALICIVIRUS
Veterinari
El FELINE CHLAMYDIA
1 yr. Lic.Nacc.N(, Signature
VACCINATION EXPIRES: 0 FELINE IMMUNODEFICIENCY
3 yr. Lic.Nacc. El Address VIRUS
\ \ `.)t \I
Month Day oar
Vacc. Serial (Lot) No. Boehringer
\ i e 4 cn 2,----c; ktffili Ingeiheirn
VAC0410001

VAC0410001 Month 1 Month DATE (Specify) Other Cat Dog SPECIES: NO/ PRI Owner's
.2._ VACCINATION E 0 >t, eii 51.0
f '"):' I VACCINA 9 LAI Name
Day Day , &
6,11. EXPIRES: i D: Altered Female Male SEX: STRiv biAJET
Year Year 3 1 Address
fe
yr. 3 yr. 1 V jgC 01
PRODUCER: 12 3 AGE: zOom F
Lic.Nacc. Lic.Nacc.X- Mo. Mo. rn
or to RABIES
0 older 12 m
Vacc. /2 (First r-5 Mo. 6t,,i
3 6) PRINT ADAPTED
Serial Y 0 -
(Lot) Letters) 4-' r''' Over 20 SIZE: gyit use VACCINATION
- Under ball
No. 50 lbs 50 20 Riot', point NASPHV
lbs.
1-.1-7 lbs. e/ktthe_ pen
0 0 $. ite_ or FORM
type
Address Signatur Veterinaria NAME: bit 51 CERTIFICATE
Veterinarian's'# PeCi. PREDOMINANT
n Ml
.i . 1 / STATE
--c O 1, Lice liir., BREED: eit
,_./. 7-) ,
o ZIP Cert. Tag Tag
`;'.. COLORS: ova TELEPHONE #: fee
/ —ft)--)1 Serial $:
.6634 - #:
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'
E: 1:1 0 0 C O 0 0 0 G G 0
Name
49) VIRUS FELINE FELINE FELINE FELINE FELINE FELINE CANINE CANINE CANINE CANINE CANINE CANINE LYME gRABIES VACCINATION
LEPTOSPIROSIS
Ingelheim Boehringer PAR DISEASE
IMMUNODEFIC CHLAMYDIA CAUCIVIRUS RHINOTRACHE PANLEUKOPEN LEUKEMIA BORDETELLA CORONAVIRIK ADENOVIRUS PARAINFLUEN. DISTEMPER RECORD
VOVIRUS
VIRL

VACCINATIUN LERTWICAVE 0 0 3 11 1
Tender Loving Car Official Proof of Vaccination
Keep this record in a safe place. Duplicate requests $10. Corporate Office Hour
Veteanory SerwRces v Mon - Fri 9:00 am - 5:00 pm
480-699-9950 P.O. Box 7479 • Mesa, AZ 85216
OWNER: Fill out sections #1-3 OFFICIAL RECORD - PLEASE PRINT CLEARLY Www.TLCVetServices.com
Last Name: First Name: re-- I
71 :2 r 177 Tidn :
Address: r1:77,1
City: rd 1 /-1 E.[ State: ZIP:
I Y a / 0
Email:
Home: 0 *;„ 7.1-1 Cell: 1 I Work: z
HIrriolilie having read and I understand the back of this document. Being aware of b ( (-/
tthheesseeffaaccttss...1[give my permission to TENDER LOVING CARE VETERINARY SERVICES X /4:11/' ./C DATE
1111 - 11 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.
111 New Client Yes No fl H ow did you hear about this clinic? Flyer from Store D Mailer D Referral El Website n Other
f tibog CI Male fl Neutered (male) 0 On Medication male) El On Medication
EliCat -PIFemale 56payed (female) CI Pregnant male) ri Pregnant
I Pe. i 2 il V Age (lcilock one): Na Age (v'clieck one):
Name': / 0 Wks 0 Wks
Breed: 1 -a.-lo Xi I ta J7 mos Breed: /--7 0. Mos
Colors: 1, 1 (1 0 i 1' m Yrs Colors: rad-7 :171 Yrs
PLEASE DO NOT WRITE BELOW THIS LINE -FOR FFICE. USE ONLY - PLEASE NOT WRITE BELOW THIS LINE
Rabies Type: KILLED VIRUS Mfg. je icailA PRICE NEXT BOOSTERS Rabies Tge: KILLED . VIRUS mfg. 111 c .-J PRICE NEXT.B1709.': -
Lot # i-:-.) '222 \ "Se/-37) C.) Tag # Woes not include 3_4 6 or 36 Lot # 9.:`, \ 9...) t':----i) (..--) TO-- roues ..1 uiclude 3-i 6 12 36
rice or boosleis.) Weeks Months A nibs Months Flee Oth605 1eis.) Weeks Months Moolho Months
Rabies Date Vaccinated: (9 / I r) i 1 '-i Rabies Date Vaccinated: ( P / ' / , ,
Rabies Vaccination Due: ( 0 / ( A WI"- $19 : C1 El Rabies Vaccination Due: CP i IV'', / $ P3'91
,7171-70A2PPvlBordetella Nasal/ Deworm cc $ IA r D131- DA2PPy / Bordetella Nasal! Deworm cc $
C131- 4-in-1 FVRCP /Leukemia / Deworm _ _ cc $ CP1- 4-in-1 (FVRCP)/Leukemia / Deworm _cc $
DA2PPy / DA2PPv+L / Corona II $ ' DA2PPv / DA2PPv+L / Corona $
Bordetella - Nasal !Injectable $ • Bordetella - Nasal 1 In'ectable $
ly_ me / Rattle Snake ' L me / Rattle Snake
Deworming (Protal 50 mg/ml) cc 11 Deworming (Protal 50 mg/m1) Co $
Cat 4-in-1 (FVRCP) / Leukemia $ 11 Cat 4-in-1 (FVRCP) / Leukemia II $
Test Heartworm I FELVIPaniol °Pas 0 Negil I I Test: Heartwoun / FELV/ Parvo/ El Pus 0 Null $
Heartworm Mfg: Cl Iverheart Max 0 Heartgard PI 0 Heartworm Mfg: 0 Iverheart Max 0 Fleartgard Plus 0
Pet's Wei ht: 0 0-25# 0 26-50#0 51 -10011 Pet's Weil ht: 0 0-2511 li 26-50# CI 51 -10011 $
Micro Chis it $ MIs. Micro Chip II $ ME..
Other . $ Qty: @ $ Qly: 0 $
Other: $ Qty: 0 $ $ Qty: 0 $
Other: $ Qt : 0 $ $ 0: 0 $
Treatment Feei,,$ Sc pt Fee: $10 $ $
y. Exam Fee(.$5 $20 Health C ificate: $ $,,----.;, CO $ f.:)-- OP
Li Waste Disposal Fee: IV -, 2 $3 1 .00 i f I Vaste Dissosal . 0 C)
gigatasginirflecol e (.,..:_wye......,' .?,....,eli, :!- 1 )
HR: L \-.) Resp.- \Y) Pet #1 Total gagateasttelle ..71 - Pet #2 Total
..
Temk\-')-:---' _ It Weight:. , /r ). Next Booster(s) Due On: ( 0 11 )0) 1 r7---- Next Booster(s) Due On: 1 ( _. 0 I kg
PHYSICAL EXAM- t..
Mx FA I al Ahoonnal 0 Next Booster(s) Estimated Price $ ' -4Z, Next Booster(s) Estimated Price $MiSUI
GeneralAppearance
Skin /Coat 11 71 NOTES! DOSAGE: pi_ - 1 Skin I Coat NOTES / DOSAGE:
Eyes ii 17 Eyes 0
Ears ii 0 , Ears [J El
Mouth/ Dental 11 ID \ \-, Mouth! Dental 1J 0
Respiratory il CI \jj I Respiratory .
HEALTH WITHI ORMAL LIMITS HEALTH W1THII4 NORMAL LIMITS (II ,,, \\ir
Yesik: Na El 'V ' \ -
1,ncinations not delivered on schedule Vaccinations-riot delivered on schedule
se effectiveness. Returning after loose effectiveness. Returning after
• booster's due date may require the booster's due date may require r:_....
additional riotropyro arpropiron Atilt, additional vaccines for proper protection
- at an additional cost to you. Sub Total: $,--.,•:,..t. N
Veterinarian: ,V.Jf CC Fee:
lf
State Lic # 1442 Date:1 Pd $ Bat $ Cast7 CC o cvc k Cashier InIt: • )TOTAL:
White: TLC VETERINARY SERVICES LLC Yellow: CLIENT/ COUNTY
\

VACCINAMM CEWFLACAV 003
Tender Lloving Ca! Official 'Proof of Vaccili 4on
VeterharySienkim, ,, Keep this record in a safe place. Duplicate re q ests $10. Corporate Office Hour.
Mon - Fri 9:00 am - 5:00 pm
480-699-9950 P.O. Box 7479 • Mesa, AZ 85216
°VIPER: - ,1 siut sections #1-3 OFFICIAL RECORD - PLEASE PRINT CLEARLY www.TLCVetScrvices,com
7
Last Name: First Name:
Address:
City: State: Zi
Email: r,„:77
Home: V- zr;73-1-[3 0 Cell: Work:
I acknowledge having read and I understand the back of this document. Being aware of If ,
these facts, I give my permission to TENDER LOVING CARE VETERINARY SERVICES kk k b DATE 6" 6-3 L -/
LLC andfor the Doctor lo heal and/or administer the vaccinations listed below, There is a $143 waste disposal fee per animal. Prescription ONLY fee $10.
Now,Client Yes d. No Cl How did you hear about this clinic? "Flyer from Store El Mailer El Referral El Website fi Other
le) El On Medication Dog) Male CI Neutered (male) P On Medication
0) D Pregnant El Cat CIFernyle 91 Spayed (female) CI Pregnant
Age ("ct-mck ono: Name: Lie cf , 0 (Age ("clock one):
o Wks Wks
4.-). Mos Breed: ',...1,111 /2 7::::- k..--- AP; 0 Mos
Yrs Colors: Yrs
PLEASE DO NOT WRITE BELOW THIS LINE POP OFFICE USE ONLY-- PLEASE DO NOT WRITE ELOW THIS LIN E
_
Rabies Type: KILLED VIRUS .,Mfg. - '17- i .e_l PRICE NEXTBOOSTERS .. Rabies Tyr: KILLED _VIRUS M g. 14...? -4.7 NI.: ji P E NEXT BOOSTERS
Lot II ) 9_ i ,, 1 ,,yy_:;:71 ":,..> _ x ) _ '...._ ( .• Tag # (DM '100141llie 3 .1 6 12 36 1_01 ;1 '_,D,: \ ) 52:1.1 _..) ) (:Th . r) (----1 Tagi# - pot et i Chide 3 I 6 12 35
F.-3,6.t.,- .7"..., IIM priced boosters.) weeks Months onihs Muntlis . , (-,,,.---..-30,r712,: PK r 1)005t6r5.) Weeks dlon41 s Llendr. 1.4unihs
Rabies Date Vaccinated: Co / 1 r) I i 1 Rabies Date Vaccinated: (i) / / ( 0 / t -r
Rabies Vaccination Due: ( 0 / ( 8 . o -1." Rabies Vaccination Due: '. ° I l i e) n / 1 r r.-- ----
1--DP1- DA2PPvlBordetella Nasal! DeworM cc MEM - ---- III - .- — DP1 - DA2PPv / Bordetella Nasal I Deworin $
51:P1- 4-inl El./RCP / Leukemia! Deworm cc $ = CP1- 4-in-1 FVRCP1 Leukemia ._ / Deworm _. cc $
DA2PPv / DA2PPv+L 1 Corona $ DA2PPv / DA2PPv-I-L / Corona $
• Bordetella - Nasal / ln -ectable $ Bordetella - Nasal I In ectable $
IL me .. / Rattle Snake L roe / Rattle Snake $
I Deworming (Protal 50 mg/m1) CC I II Dowormmg (Protal 50 mg1m1) c $
CaLi:M-1 MRCP) / Leukemia Cat 4-in-1 (FVRCP) / Leukemia $ - ----
I Test: Heartworm / FELVI Parvo/ oPos0Ne $ Test: Heartworm I FELV/ Panto/ El pas ON
• Heartworm Mil: CI Iverheart Max ID Heart' aid Plus 11 • Heartworm MI': CI Iverheart M CI Heart arc! Plus El
• Pets Wei lit: 0 0-254 0 26-504 0 51-1004 II Pets Wei ht: 0 0-25ff n 26- 0# o 51-1004 $
rril
• Micro Chi # Micro Chi 11 $
I Other: Qty: @ $ I Other: 1$ Qt : 0 $
I Other: $ Qt : 0 $ 1 Other: MIMI 01: @ $
• Other: $ Or : 0 $ Other: $ Q : @ $
Ill Treatment Fee: $ Scrist Fee: $10 $ 11111.- II Treatment .-e : $ Scri t Fee: $10 FAIIIIMM
E.Exam Fee. $5 ',20 Health Certificate: $ MEM ......_. WM= ... __ __.._ . , xam Fes- $5 20 R 10 Certificate: $ MOM MIN
ffl Waste Disposal Fee: 11 ' $2 $3 rIMEINI=IM _40 Waste Dis o-161 Fee: $2 $3 Mill 1M MOM=
(Total daes not include NM FIR: ' ,, Rev; (...) Pet #2 Total goci al ft adr lose s i la i include d , ,s 7- y; ,-- . -, , r f i rr i
HR: L 0 Resp!' \(1) ‘,..-,--, c) Pet I/1 Total CIC transaction eel action ea.) 4t flzkyr)(.._/
TemPVY2' _. 4 Weight: ,. -.10 •(- MI gm Temp: t. Weight 1‘-l• ("k 1
PHYSICAL EXAM: — ext Booster(s) Due Oft PHYSICAL E M: Next Booster(s) Due On: (9 In .--)
Oar Abnormal 0 Next Booster(s) Estimated Price RCIIM . V , General Appearance kenal ril Abnormal 0 Next Booster(s) Estimated Price SWAIM
GeneralAppearance
Skin/Coal 171 NOTES / DOSAGE: 19 _ .... A Skin/Coat CI NOTES / DOSAGE: ( Cl -
Eyes CI Eyes o
Ears CI a . Ears M il
Mouth / Dental Efl CI ,, \--" Mouth / Dental 0
Respiratory CI Respiratory $ a
HEALTH WITHIN-NORMAL LIMITS HEALTH WIT IN NORMAL umrrs • ,
'kV LI No El ..Ye ;i5 No El
",ccinations not delivered on schedule Vaccin9idn, riot delivered on schedule
.e effectiveness. Returning after loose eFfel iveness. Returning after
. booster's due date may require the boost r's due dale may require
additional vaccines for prop , r protegion . additional accines for proper protection r-C7 . '
at an additional a alto you ' r 1 P -if c- ,, at an additional cost is you. Sub Total: $("-7.9t, . _,..,
.-"-• I 1 11 1 • 1
Veterinarian: j. 11_,LI Lour' Tech. Ina: i CC Fee: 0 -
State Lic # 1442 Date: ( 1;" Bal $ CasFIJEI CC o cvc Cashier Ina: .)TOTAL:
White: TLC VETERINARY SERVICES MC Yellow: CLIENT / COUNTY

Month to Month /0 DATE Please Other Cat Dog No. Last
SPECIES: Owner's
VACCINATION specify 0 0 iiga-qf ffia
Day IS Day ..c / Name
' ' VACCINATED: Male SEX: Street Fe
Year Pi EXPIRES: Year / Neutered Female (.11 S &Address
3 0 % D
5 Dog 12 3 AGE: _CA
Vaccine 2,5? 3 I PRODUCER: mo. mo.- RABIES
t yr. yr. CV'S or 12
Serial 9 Lic. Lk. older mo. kedk_
(Lot) 9 f /Vaccine /Vaccine (First i 0 X City PRINT
No. A 3 ClVdir Over 20 -
0 X letters , - Under SIZE: use VACCINATION
ii SO SO 20 NASPHV
i 35 lbs. lbs. lbs. s4p First ballpoint
Address: Veteri 4- 0 jX. 0 e Form
' AT . 7-010Pctit pen 51
.) / . A Ins VETERINARIAN: NAME 1 i h or
S.--J-i-fer 01( , ft 11.eager rPREDOMINANT artr type
(
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1'4 1 _ .4 h 7
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(ILI 17 COLORS: M5zi .209 Tag
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your
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DATE was
2

_
RABIES VACCINATION CERTIFICATE . Tag tee $:
'''' ' 4.1 N•11 ADAPTED NASPHV FORM 51 Tag #:
Owner's Name& Address PRINT - use bell point pen or type Cert. Serial #:
PRIM' .. FIRST, MI • TELEPHONE
—K.— --c- ,...._..) ,-- r„ -IN v.-- Cc-K.__
_
NO. STREET, 1 t cp-,y STATE ZIP 3 03us,
1 c3L1 i Li NI 1 -7( tt' v ,11")I.....L k. L.A,„.. 0 Z
SPECIES: e SEX: AGE: - SIZE: PREDOMINANT BREED: COLORS:
Dog Male '3 Mo. to 12 Mo. >g:P Under 20 IbA r. - r
Cat 0 Female 0 12 Mo. or older 0 20 - 50 lbs Li , ' ----- X, fl,..)').Q0
Other 0 Altered W Over 50 lbs. : ---...,,,...) ...O. ll..."
(Specify) e
a yi2-77/f) t.i:C_
DATE VACCINATED: PRODUCER: i
eterina ' 30LI
License No;- ---.
Month Day Year
(First 3 Letters)
Veterinarian's
1 yr. Lic.Nac46
VACCINATIQN EXPIRES: Signature _Spay_Neuter_thsk____
L Il kilitiLl 3 yr. Lio.Nacc. 0
Month bay Year 'z i --;) i :1 [1.0 Address - 12416 NI 28th Dr., #16
Wm Serial (Lot) No. Phütflr, AZ 85029
VAC0410001

RABIES VACCINATION CERTIFICATE
OWNER'S INFORMATION:
RESCUE ANGELS HELPING AM, P2184279 (623) 7428229
LAST NAME TARSI- RAI iE PERSON ID TELEPHONE NUMBER EXT.
12402 W PERSHING ST EL MIRAGE AZ 85335
STREET ADDRESS APT CITY STATE ZIP CODE
ANIMAL INFORMATION
DOG NEUTERED 1/6/2008 LARGE • SIBERIAN HUSKY MIX
ANIMAL TYPE ANIMAL SEX ANIMAL DATE OF BIRTH SIZE PRtmARY BREED SECONDARY BREED
A2811424 SKY —Toil ial_ WHITE
ANIMAL iD ANIMAL NAME hlICROCHIP NUMBER ',VINARE COLOR SECONDARY COLOR
VACCINATION INFORMATION
RABDOMUN SPEC 12 Months I 10/10/2013 10/10/2014 10/10/13
VACCINE PRODUCER VACC. LENGTH DATE VACCINATED VACCINATION EXPIRES PRINT DATE
KILLED ,4„.Zift-, Maricopa County
Animal Care & Control
VACCINE TYPE VETERINARIANS SIGNATURE 2500 S 27th Avenue, Phoenix, AZ 85009
- (602) 506-7387
S300570F
VACC. SERIAL NO. VETERINARIANS UCENSE NUMBER

2 VIRUS
RECORD PARAINFLUENZA CORONAVIRUS LEUKOPENIA RHINOTRACHEITIS IMMUNODEFICIENCY
DISTEMPER ADENOV1RUS PARVOVIRUS BORDETELLA LEUKEMIA CALICIVIRUS CHLAMYDIA Boehringer
DISEASE PAN Ingelheim
LEPTOSPIROSIS
VACCINATION RABIES LY1V1E CANINE CANINE CANINE CANINE CANINE CANINE FELINE FELINE FELINE FELINE FELINE FELINE VIRUS
y Name 0 0 El 0 E 0 0 0 IE 0
i,v.
bv St es26a
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#: s'A.,,.„„&i.,,,i 7, AZ
$: Serial : c-:
fee #: TELEPHONE COLO 6—Tfe k. 1.,.
Tag Tag Cert. ZIP No. Scoetsclaia,
U.1.4...a. 97/6
BREED: )ç License
#
MI STATE chow (.)--/IreffIDO
CERTIFICATE 51 PREDOMINANT NAME: Veterinarian's Veterinarian's Signature Address
FORM type or 0
pen lbs. lbs. .....--
NASPHV point 20 lbs 50 50 No.
VACCINATION ball CITY SIZE: Under - 20 Over C'?-37C.05 (Lot)
use - 0 Letters) Serial
ADAPTED PRINT Mo.X 3
12 older (First Vacc.
RABIES to or 0 2
Mo. Mo. Lic.Nacc. Lic.Nacc. .b
FIRE, AGE: 3 12 PRODUCER: • 3
0r. :J' yr. 1 yr. 3
3 ear 6-- Year Number
&Address /1 STREET SEX: Male Female Altered / i EXPIRES:
Name VACCINATED: '-- Day Day License
/ LAST 0 0 VACCINATION
Owner's PRINT NO. SPECIE Dog Cat Other (Specify) DATE 5 Month Moisitih VAC0410001

RABIES VACCINATION CERTIFICATE Tag fee $: VACCINATION RECORD
ADAPTED NASPHV FORM 51 Tag #: Name
Owner's Name & Address PRINT - use bail point pen or type Cert. Serial #: RABIES
PRIM' glavd
FIRaitaintif 0 LYME DISEASE
gle, TEtPalE
NO.i97 9TREN. day, ave 04041 (e.a6 "I .3 0 -5 LI CANINE DISTEMPER
CITY STATE0 i ZIP 6,53940 o CANINE PARAINFLUENZA
SPECIkS ) SEX: AGE; 0 CANINE ADENOVIRUS 2
Dog ?f Male 0 3 Mo. to 12 Mo. g SIZE: Az J PREDOMINANT im -yu o BREED: COIN g , 0 CANINE PARVOVIRUS
Cat 0 Under 20 lbs. ,giV
Female PO rv 12 Mo. or older 0 20 - 50 lbs lil 0 CANINE CORONAVIRUS
Other 0 Altered Over 50 lbs. D NAME : , 0 CANINE BORDETELLA
(Specify) Jaja D LEPTOSP1ROSIS
DATE VACCINATED: PRODUCER: 0 FELINE LEUKEMIA VIRUS
C, ill /II int Veterinarian's # 0 FELINE PANLEUKOPENIA
Month Day Year L' ense No. 0 FELINE RH1NOTRACHEITIS
(First 3 Letters) Veterinaria D FELINE CALICIVIRUS
VACCINATION EXPIRES: 1 yr. Lic.IVacc.T 0 FELINE CHLAMYD1A
Signature /e.:111 .111"
6 i C;t 3 yr. LIc.Nacc. 0 O FELINE IMMUNODEFICIENCY
I Address
Month Day Year g t SeV - VIRUS
Vacc. Serial (Lot) No.
VAC0410001 Boehringer
4) (5.\ Ingelhehn

uoll,Z, WACCIAATIMiii CiEitTFLICEIr 0 03A 0 0
ire ricieft Louhg Cat ',:, ,' - official Pr6of of Vaccinton .,.
Veterfinau Seys vkie -1 Keep this record In a safe place . Duplicate re ests $10. ' Corporate Office Hours:
Mon - Fri 9:00 am - 5:00 pm
480-699-9950 P.O. Box 7479 • Mesa, AZ 85216
T OWNER: Fill out sections #1-3 * OFFICIAL RECORD - PLEASE PRINT CLEARLY www.TLCVetServices.com
,
I Last Name; ;) /2 4::: IA .// ,_ 1 161::: tx_ . 4,,, (,,,,,, iii 20: 1 i ,, c 6F:gi rst Ni ame: /(-_. / -'-j- / [
Address: I it...' I /191111111 2 0 0 m II [
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Email: • [
Home: Me - -2) 2. (‘-7 - 1 —1-5 Ce[I: , - 1 - M , Work: [
I acknowledge having read and I understand the back of this document. Being aware of ----‘ i 6.
these facts, I give My permission to TENDER LOVING CARE VETERINARY SERVICES G ( 40,':' : . ',.' /I i it DATE (X% .4._ / - 7 / /
LLC and/or the Doctor to treat and/or administer the vaccinations listed below. There is a $1-$3 waste disposal fee 1- animal. Prescription ONLY fee $10.
n New Client Yes )No n How did you hear about this clinic? hilyer from Store El Mailer [I Referral 111Website n Other
Rabies Type KILLED ,,, VIRUS . im ....- Mfg. 1 .. y 11 -f--- i. 1- k_.... PRICE NEXT BOOSTERS PRICE NEXT BO S, RS
Lot -// i--7) '--,_?3 \ . '': _0 (---4.-..-, Tag # (Does slot Ira& 3_4 6 23 (i)uus nui inyliafe 3,4 6 12 3,
I ,`-'5-.W7(1fis." _ Pfice onnosters.) Weeks Aanihs Months 4.1onilr, Voce of b.,06'5112S-) Weeks Months Months Months
Rabies Date Vaccinated: / 9. / F, / ' 1
Rabies Vaccination Due: IP / 1 9) / 14-3- $ -:._ -1'1 114
I DP1- DA2PPv / Bordetella Nasal / Deworm cc $
C11.-422-1 Alikemia / Deworm cc $
DA2PPv / DA2PPv-Ft. / Corona $ MI MI.:
•
Mill
-1111
_......_.. _.
I
Heartworm i 1 I II ard Plus El \
Pets 1 S
I • 1 I I 1
Qt • ' P $
• Q . ' Co $
I Qt 0,$
• i i
Exam :- ' '.
i I
HR: \ \'4 t, ) R esp. A '-- Pet #1 Total cic 1RdaId°es Ira don " nclude fee.) " i tOrtf kat, —Tri *.' fira: k..,H ted I ! , HR- ' Resp: Pet #2 Total obl3Idoes C/C IrarisacIinn not include fee.)
Temp: \ k\ t\Weight: I i ''(..... kin I ri 1 i rt., / - •rlip: Weight:
PHYSICAL EXAM: Next Booster(s) Due On ((ft 11 t n i 1 PHYSICAL EXAM: Next Booster(s) Due On: .I
General Appearance llamal Abnonnal n Next Boostef(s) Estimato Price $1 0 General Appearance Normal 0 Abnormal El Next Booster(s) Estimated Price
,
Skin /Coat El , CI NOTES /DOSAGE: DOSAGE: ci, ( Skin/ Coat 0 0 NOTES / DOSAGE:
Eyes 1_1 Eyes 17/ 0
Ears El ri Ears ri ci
Mouth/ Dental El o , Mouth / Dental 0 0
Respiratory 11 CI Respiratory I7 0
HEALTH WITHIKTNORMAL LIMITS ) \‘-A \ HEALTH WITHIN NORMAL LIMITS
Yes_Er....,_ No 0 Yes 0 No 0
'',ccinations not delivered on schedule Vaccinations not delivered on schedule
ie effectiveness. Returning after loose effectiveness. Returning after
...- booster's due date may require the booster's due date may require ....-
additional vaccines for proper protection additional vaccines for proper protection C q .1 f- -
at an additional cost to you. 1 % , al 1, an additional cost to you. t. i . Sub Total: $ -,-
Veterinarian: iOn &,144.4. (41TIAM.... ' .4 Location: Tech. hit: CC Fee: $-• (4\ Ts --
State Lie # 1AA2 Date:( Pd $ Bal $ Cash o CC o CVC Cashier triit412\r-"" TOTAL: $.
hit ETERINARY SERVICES LLC Yellow: CLIENT / COUNTY

Month Month DATE (Specify) Other Cat Dog SPECIES: NO. Owner's
AC0410001 a 2 i
VACC1N1TION i 0 I: X
Day 10 Day --z.).:)/ VACCINATED: praNnithri Name
1 i I Male SEX: 9/S9EETN &
,..) EXPIRE, 'j Altered Female Address
Year ear
yr. 3 yr. 1 0 0 ck,'
io. L. PRODUCER: 12 3 AGE: Laiit
N Lic./Vacc. Mo. Mo.
acc. or to Ithimed RABIES
LI _ 12 m
Vac. i (First older Mo.
Zi 3 IQ PRINT ADAPTED
one Sena/ 0 co' i -
mL Package (Lot) Letters) Over 20 SIZE: j-iy use VACCINATION
)7 - Under ball
vial No. 50 50 NASPFIV
of contains il lbs. lbs 20 ....„6.e4te point
Canine lbs. pan
diluent, a Modified Parvovirus Adenovirus EL — n jrkr gkeAtiv or FORM
& one type
one dose Address Signature NAME: ek - 51 CERTIFICATE
Parainfluenza- Veterinarian's Veterinarian's h PREDOMINANT j
vial STATE MI
disposable of Live - #
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vaccine, Distemper- License BREED:
Type 2.-
syringe a Virus Vaccine C. L) •
0 o. ("L ,7 tahal-eggi ZIP Cert. Tag Tag
2- . % 5 , TeLn COLORS: TELEPHONE #: fee
MADE 0 ,.. :. 62-10 Serial $:
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