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25021 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
El New XRenewal Permit # y-4 -
Name: cY1.\' 1 qe.1 t Kennel Name:
Mailing Address:51 6i 3 54 ),9-? Kennel Location: / 9
City G- 1 , AZ ZIPfik County Supervisorial District
Home Phone: 1•86)--- .3"F 37/c, / 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
I/We assume complete responsibility for the kennel at the premises for which I/we are making
appltion for a permit and understand that "kennel" means an enclosed, controlled area, inaccessible to other
anirnals, in which a person keeps, harbors or maintains five or more dogs under controlled conditions (ARS 11-
1001).
!/We certify that the kennel has been approved by the local zoning authority (if applicable) at the
s for which I/we are making application for a permit.
I/We certify that I/We have 23 dogs and that the kennel meets the definition in statute.
I/VVe certify that I/We have not been convicted of a violation of A.R.S. §§ 13-2910 (cruelty to animals)
or 13-910.01 (dog fighting), or any other state, county or municipal animal welfare law. (Violations of license
and leash laws DO NOT apply.)
I/VVe certify that all dogs over the age of three (3) months that are kept, harbored or maintained on the
premi es of the above named kennel have been properly vaccinated against rabies by a veterinarian licensed to
practióe in the state of Arizona and that a current vaccination certificate signed by a licensed veterinarian is
maintained on the premises for each dog.
I /We certify that I/We are submitting a valid copy of the rabies vaccination certificate for each
dog with this application.
I/We understand that a dog remaining within the kennel is not required to be licensed individually under
ARS 1A-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.
I/We understand that a person who fails to obtain a kennel permit under ARS 11 -1009 is subject to a
of twenty-five dollars in addition to the annual fee.
INVe understand that a person who knowingly fails to obtain a kennel permit within thirty days after
notification from the county enforcement agent is guilty of a class 2 misdemeanor.
10."-}e4 Is this kennel permit being obtained for the purposes of operating a business including but not limited to
breed s, groomers or boarding establishments? (Please check one) YES 1 --"R10
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. fi—i- 1/VVe certify that the kennel permit is being used solely for the purpose of licensing my own multiple
companibn dogs in my household.
VWe certify that all of the information VWe have provided is true and accurate under penalty of law.
Applicant Signature
Applicant Signature
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 Animal Care and Control
2500 S. 27th Avenue
Phoenix, AZ 85009-6797
(602) 506-7387
http://pets.maricopa.dov
Receipt Number: R13-208340 Receipt Date: 10/3012013
Person ID: P0999096
Phone: 480 9883401
BIMINI KENNELS
5193 S 158TH ST 10/30/2013 2:22:06PN
GILBERT, AZ 85296
Item: Animal ID: Reference No: Price: Each: Amount:
KEN PERMIT A7777777 $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
KJENSEN EBUSOFF
RABIES VACCINATION CERTIFICATE
Rabies Tag Number
NASPHV Form 51
Owner's Name & Address PRINT - use ballpoint pen or t ype
Lash , First M.I. Telephone
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SPECIES: , SEX: AGE: SIZE: PREDOMINANT BREED: COLORS:
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Cat Female 12 mo or oldet'tps. 20 - 50 lbs. 0 .2.,t)(A. l146,;,1 i i i))1.1-tx"
Other 0 Neutered Over 50 lbs. 91,s NAME:
Please specify
DATE VACCINATED: . VETERINARIAN:
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Month Day ' Year License No.
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1 i lit 1663 EAST 1;, ,‘,` , ,OAD #10';
Month Day ' Year 1g i S 5 A Address:
Vaccine Serial (Lot) No. Gil. BORT
RABIES VACCINATION CERTIFICATE
Rabies Tag Number
NASPHV Form 5 1
Owner's Name & Address PRINT - use ballpoint pen or t ype
Last First M.I. Telephone
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No. Street City State Zip
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SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS:
Dog 12r Male 0 3 mo.- 12 mo. Under 20 lbs. 0 ..‘ 1... • d:?1 e- it:—
Cat 0 Female 0 12 mo. or older 20 - 50 lbs. 0 0 OVIiettrikirt
Other 0 Neutered 0 Over 50 lbs. NAME:
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DATE VACCINATED: VETERINARIAN:
PRODUCER: A ,., _ "••••1 16c II—
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3 yr. Lit. /Vaccine Veterinarian's Sigetfiest..4b I %OS!' .
1 / 9 1663 EAS . . .>-,0 ff10.
Month Day ' Year l''g 1 'S A Address:
Vaccine Serial (Lot) No. Gil ' Q'5296
RABIES VACCINATION CERTIFICATE
Rabies Tag Number
NASPHV Form 51
Owner's Name &Address PRINT - use ballpoint pen or type
Last First M.1. Telephone (—A 'Ci G
No. Street City State Zi • __
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SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS:
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Cat Female t. 12 mo. or older WI. 20-0 5 lbs. 0
Other 0 Neutered Over 50 lbs. tilL. NAME:
Please specify Pezt - LVc,t22
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DATE VACCINATED: VETERINARIAN:
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Month Day ' Year License No.
First 3 letters
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3 yr. Lic. / Vaccine 4;1...., Veterinarians Veterinarian's Signature
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Month Day ' Year I (351 Address: 1663 EAST f ,' ,,OAD #105
RABIES VACCINATION CERTIFICATE Tag fee $:
ADAPTED NASPHV FORM 51 Tag #:
Owner's Name & Address PRINT - tree ball point pen or type Cert. Serial #:
PRIST NVV FIRST TEL§ 1, 0,
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Cat 0 El Female ,1?,."-T2 Mo. or older Z"--- 0 - 50 lbs D
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DATE VACCINATED: PRODUCER: Veterinarian's # bC
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Month Day Year (First 3 Letters)
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1 yr. Lic.Nacc. D Signature
VACCINATION 8 , / EXPIRES: iv
3 yr. Lic.Nacc. .1 l?'''' vl 6111. Address
Month Day Year
Vacc. Serial (Lot) No.
VAC0410001
RABIES VACCINATION CERTIFICATE Tag fee $:
ADAPTED NASPHV FORM 51 Tag #:
Owner's Name & Address PRINT - use ball point pen or typo Cert. Serial #:
FNe'37 1 LAST Fl '}. i_...N . MI TELEPHONE
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SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS:
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Cat 0 Female /fg 12 Mo. or older ;4 20 - 50 lbs 0 //)C.-1/7 , eh (.1 AlA
Other D Altered El Over 50 lbs. )8 NAME:
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DATE VACCINATED: PRODUCER: Veterinarian's # T) h 7
3/ / / Nag License No.
Month Day Year (First 3 Letters)
Veterinarian'
1 yr. Lic.Nacc. 0
VACCINATION EXPIRES: Signature ACI-M ,(10--ed
3 yr. Lic.Nacc. Iig--e."------ .
F 3‘ /y Address
Month a y Year
Vacc. Serial (Lot) No.
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VAC0410001
RABIES VACCINATION CERTIFICATE
Rabies Tag Number
NASPHV Form 51
Owner's Name &Address PRINT - use ballpoint pen or type
Last First MI. Telephone
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No. Street City State Zip
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Cat 0 Female jai 12 mo. or older Vi 20 - 50 lbs. 0 U/4'.1,4rYleAs1f%
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Month Day ' Year License No.
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9 i 19
Month Day ' Year BSA Address: 163 F
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Vaccine Serial (Lot) No. GI: El'
RABIES VACCINATION CERTIFICATE Tag fee $:
ADAPTED NASPHV FORM 51 Tag #:
Owner's Name & Address PRINT - use bell point pert or type Cert. Serial #:
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Veterinarian's # ---1
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Month Day Year (First 3 Letters)
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3 yr. Lic.NaccX1 -- Address
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VAC0410001
RABIES VACCINATION CERTIFICATE Tag fee $:
ADAPTED NASPHV FORM 51 Tag #:
Owner's Name & Address PRINT - use ball point pen or type Cert. Serial #:
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Other 0 Altered D Over 50 lbs. D Nft1Et
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DATE VACCIVATED; PRODUCER:
Veterinadan's # j_fir6j.ir;
ORM License o.
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Month Day Year (First ' Letters)
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1 yr. LicJVacc. D Signature
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3 y r. Lic.Nac e.Np7 l Address
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Month Day Ye I 1 7°
Vacc. Serial (Lot) No.
VAC0410001
VETERINARY CLINIC OWNER OF ANIMAL
Cornerstone Animal Hospital Bonnie Yarnell
1663 East Ray Road 5193 S.158th St
Gilbert, AZ 85296 Gilbert, AZ 85298
480-857-9229 County:
This is to certify...
THAT I HAVE VACCINATED THE ANIMAL DESCRIBED BELOW.
Patient information...
PATIENT: Francine TAG NO: 18201B
SPECIES: Canine WEIGHT: 0.00
SEX: Female AGE: 5Y
Color and markings: White
Signed _t4.4,139 4Z, 7404 Al,
Daniel Burke, D.V.M. License:
Vaccinations done...
10/22/2013 DB Rabies Canine, 3yr, #18201B
10/21/2016
5/6/2009 DB DA2P-CPV Booster 5/6/2010
VETERINARY CLINIC OWNER OF ANIMAL
Cornerstone Animal Hospital Bonnie Yarnell
1663 East Ray Road 5193 S.158th St
Gilbert, AZ 85296 Gilbert, AZ 85298
480-857-9229 County:
This is to certify...
THAT I HAVE VACCINATED THE ANIMAL DESCRIBED BELOW.
Patient information...
PATIENT: Mable TAG NO: 18198B
SPECIES: Canine WEIGHT: 0.00
SEX: Female AGE: 8Y
Color and markings: Blue
Signed 84..4 2I1.14
Daniel Burke, D.V.M. License:
Vaccinations done...
10/22/2013 DB Rabies Canine, 3yr, #18198B
10/21/2016
RABIES VACCINATION CERTIFICATE Tag fee $:
ADAPTED NASPHV FORM 51 Tag #:
Cert. Serial #:
Owner's Name & Address PRINT - use ball point pen or type
PRINT LAST FIRST, MI TELEPHOLIE
(1. ‘ €_. i-\56-1-88 -516'
LI 61/4(t‘ .1 \ ,A1-ATE IP
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Cat El Female 12 Mo. or older 14 20 - 50 lbs Ei UkAtIN--SW..- L( 4 4
Other 0 Altered Over 50 Ibs. 0 NAME:
(Specify)
DATE ACCI ATED: PRODUCER: Veterinarian's #
F. License No.
1 ) ?
Month day Year (First 3 Letters) Veterinarian'
1 yr. Lic.Nacc. 0 Signature 4 .I4& IV
VACCINATION E PIRES:
C] 3 yr. Lic.Nacc Address
g 7 1 70 1 1 S— A 410
Mont( a Year
Vacc. Serial (Lot) No.
VAC0410001
--.
RABIES VACCINATION CERTIFICATE Tag fee $:
ADAPTED NASPHV FORM 51 Tag #:
Owner's Name & Address PRINT - use ball point pen or type Cert. Serial #:
PRINT LAST , FIRST , MI TELEPHONE_ ,
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NO 'STREET CITY, STATE ZIA 6 2,98
5 n6 (55-m-i--- (-7 : ( 2.4?-1.k. A
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Cat 0 Female 0 12 Mo. or older y 20 -50 lbs 0 -..'litt iNee-•
Other 0 Altered tf., Over 50 lbs. NAME:
(Specify) _
'c:15b3r .-
DAT VACCIN ER: PRODUCER: Veterinarian's # q 919 s
1 i l I VIM t License No.
i
Mont Da y% Year (First 3 Letters)
Veterinarian'
1 yr. Lic.Nacc. 0 Signature
VACCI VATION EXPIRES:
3 yr. Lic.Nacc. Address
q 1 ) • 1
Month Day Day Year ..1,701 I
Vacc. Serial (Lot) No.
37
VAC0410001
VETERINARY CLINIC OWNER OF ANIMAL
Cornerstone Animal Hospital Bonnie Yarnell
1663 East Ray Road 5193 S.158th St
Gilbert, AZ 85296 Gilbert, AZ 85298
480-857-9229 County:
This is to certify...
THAT I HAVE VACCINATED THE ANIMAL DESCRIBED BELOW.
Patient information...
PATIENT: Lyle TAG NO: 18199B
SPECIES: Canine WEIGHT: 0.00
SEX: Male AGE: 13Y
Color and markings: Black
Signed
Daniel Burke, D.V.M. License:
Vaccinations done...
10/22/2013 DB Rabies Canine, 3yr, #18199B
10/21/2016
VETERINARY CLINIC OWNER OF ANIMAL
Cornerstone Animal Hospital Bonnie Yarnell
1663 East Ray Road 5193 S.158th St
Gilbert, AZ 85296 Gilbert, AZ 85298
480-857-9229 County:
This is to certify...
THAT I HAVE VACCINATED THE ANIMAL DESCRIBED BELOW.
Patient information...
PATIENT: Alex TAG NO: 18200B
SPECIES: Canine WEIGHT: 0.00
SEX: Male AGE: 11Y
Color and markings: Cream
Signed Th44441
Daniel Burke, D.V.M. License:
Vaccinations done...
10/22/2013 DB Rabies Canine, 3yr, #18200B
10/21/2016
RABIES VACCINATION CERTIFICATE Rabies Tag Number
NASPHV Form 51
Owners Name & Address PRINT- use ballpoint pen or type
First M.I. Telephone
Last
(10411 je 980 ' 1 W e 5-10 1
Ckirile, 1 ( Zip
No. Street City State
.11 $ I 5. +I, 5 I- 61; LA- #1 852'718
SI AGE: SIZE: PREDOMINANT BREED: COLORS:
SPECIES: SEX:
Dog A Male 4 3 mo.- 12 mo. 0 Under 20 lbs. IE i 61C, Lit,
Cat 0 Female 0 12 mo. or older IX 20 - 50 lbs. 0 ati./Let,i6 be.34e..e/
Other 0 NeuteredX Over 50 lbs. 0 NAME:
Please specify P.a-prf2--r
DATE VACCINATED: VETERINARIAN:
CY4 / Zeit/ 3 PRODUCER: ji 4.......- 4
I --"N Veterinarian's #:
Month Day Year License No.
First 3 letters)
' ,7:6.....,,,..u.if
VACCINATION EXPIRES: I yr. Lic./Vaccine 0 Veterinarian's Signature /
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1 It 7 c.., Address: 110103 er- - Akiy no4 A'/05
Month Day Year
Vaccine Serial (Lot) No 612 lit--1-, At 8C2-`1 4
RABIES VACCINATION CERTIFICATE Rabies Tag Number
NASPHV Form 51
Owners Name & Address PRINT - use ballpoint pen or type
Last First 11.1. Telephone fp" k,
9 tie' -1Y0 /
No. Street City State Zip
Si' 6,',/b.--t- AL S. 5ziv
5 /73 5./S
SPECIES: SEXT AGE: SIZE: PREDOMINANT BREED: COLORS:
Dog 21. Male 0 3 mo.- 12 mo. 0 Under 20 lbs. 0 1))/•vt A- d!
Cat 0 Female EY 12 mo. or older [;), 20- 50 lbs. 0 Otina 5 e. Cr45.4 1
Other 0 Neutered 0 Over 50 lbs. 0 NAME: LtAl ;4 4.-
Please specify
DATE VACCINATED: VETERINARIAN:
LL
4"-- w (3 PRODUCER: ivi /6- 0 s.
Veterinarian's #:
Month Day ' Year License No.
(First 3 letters
VACCINATION EXPIRES: I yr. Lit. /Vaccine 0 /
3 yr. Lie. /VaccineA Veterinarian's cam „..5.ta Signature ,...,, A,„., „co,
( z I it, Nkcip; i -4
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Month Day ' Year
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RABIES VACCINATION CERTIFICATE Tag fee $:
ADAPTED NASPHV FORM 51 Tag #:
PRINT - use ball point pen or type Cert. Serial #:
Owner's Name & Address
FANT LAST , i ST wow
kiNfrk.Ak tP_, . N)1 9 1
NO. .., STREET \ CITY xl BgP62,q5
i Ct .
SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS:
Dog Male 3 Mo. to 12 Mo. 0 Under 20 lbs".._
Cat 0 Female 12 Mo. or older 20 -50 lbs 0 ‘:e,
Other 0 Altered Over 50 lbs. 0 NAME: IA . It.,
(Specify)
DA - \1CCIN PI ED: PRODUCER: Veterinarian's # Li Cli (0 S
License O.
4 1 \
Month Da Year (First 3 Letters) Veterinarian'
1 yr. Lic.Nacc. 0 Signature
VACCIN CI TION 1 PIRES: 1 k...,( 3 yr. Lic.NaccOi wi 0 t, „.._ Address
........
Month Day Year
Vacc. Serial (Lot) No. 7
VAC0410001
RABIES VACCINATION CERTIFICATE Tag fee $:
ADAPTED NASPHV FORM 51 Tag #:
Owner's Name & Address PRINT - use ball point pen or type Cert. Serial
PRINT LAST ARST
Lik(Vik. li nonvoe. MI TEl
48 A - 3 LW\
NO. STREET CITY
M95 5 15 0-1/41^- -1-' cii I 1 w-i--- ZIP,,
86 2_ci 2,
SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED:
Dog ''Er Male 0 3 Mo. to 12 Mo. 0 Under 20 lbs. 43 COLORS:
Cat 0 Female f,K, 12 Mo. or older *20 - 50 lbs El vs0Cv.)2_ c& (\
Other 0 Altered y
Over 50 lbs. 0 NA E:
(Specify)
DATE VACCI ATED: PRODUCER: Lfrl (-1'
Veterinarians ' # C.; c
CI 7 I i PF I License No./
Mohth ay Year
(First 3 Letters)
Veterinarians
TCTI ATI EXPIRES: 3 1 yr. L. Lic.Nacc. . 0 Signature
yr. ic. Nacc y_ 1 ti ot 1 Address
Month 1 7 ay i i 1 Year
3?
Vacc. Serial (Lot) No.
wernA 1 00111
VETERINARY CLINIC OWNER OF ANIMAL
Cornerstone Animal Hospital Bonnie Yarnell
1663 East Ray Road 5193 S.158th St
Gilbert, AZ 85296 Gilbert, AZ 85298
480-857-9229 County:
This is to certify...
THAT I HAVE VACCINATED THE ANIMAL DESCRIBED BELOW.
Patient information...
PATIENT: Gracie TAG NO:
SPECIES: Canine WEIGHT: 0.00 6.
SEX: Female AGE: 6Y
Color and markings: Black and Brown
00.440, ef 4444. 214,. II. $4.
Signed I
Daniel Burke, D.V.M. License:
Vaccinations done...
8/28/2012 DB Rabies Canine, 3yr 8/28/2015
C .E RTIF IC NT
VETERINARY CLINIC OWNER OF ANIMA'
Cornerstone Animal Hospital Bonnie Yarnell
1663 East Ray Road 5193 S.158th St
Gilbert, AZ 85296 Gilbert, AZ 85298
480-857-9229 County:
This is to certify...
THAT I HAVE VACCINATED THE ANIMAL DESCRIBED BELOW.
Patient information...
gz--14s
PATIENT: Marge TAG NO: 18095A
SPECIES: Canine WEIGHT: 0.00 5_ R
SEX: Female AGE: 4Y
Color and markings:
Signed
Daniel Burke, D.V.M. License:
Vaccinations done...
8/28/2012 DB Rabies Canine, 3yr 8/28/2015
6/10/2009 DB DA2P-CPV Booster 6/10/2010
6/9/2008 BB Rabies Canine, 1yr, #\
VETC 1213 038717
- OFFICIAL VACCINATION CERTIFICATE
Affordable Pet Healthcare we
VetcoClinics.corn 1 -877-838-7468
Last Name CA Store New Customer? Y I
Hit
Apt/Sulte#
11]
cy Zp Code Spouse/Partner's Name
Phone e-mail (IMPORTANT FOR COMMUNICATION)
HOW DID YOU HEAR ABOUT US? Online Search Store Flyer Friend Postcard Email Call Other
Pet's Pet's
Name Dog Cat Name Cat
-
Breed , r' - — Sex:) F, Spay/Neuter: Y 6 Breed Sex: M F Spay/Neuter: Y N
Color /7/ DOB: Color DOB:
Weight 1-1 On Meds? Y„:N.Avhich, Weight n s? Y I eh;\
Pregnant? Y N On HW/Parasite Prevention? Y Rregnant? On HW/Parasit Prekention. Y N
T: P: --1,..: R: . / -,, Gen.App.-ki, is--R--- A \ P: \.\ R:I.U.Gen.APp.
Skin Eyes Ears Mouth SkN\ , Eyes! \ 'Ear klouth
(,....2:1) ......,.—, \7--- ,,, 1. I • 37
RAB-10 SQ Killed / ML W LH: RH :, 1YR /- RABIES: \SQ Ki ll / MI1 - W LA I' RH 1 R $
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mFdi k - A-- t i -. L.-- ) e i ' 0-- Tag # • MFG '* \ Tag # • / i .."1
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Vac Nein' (,..1 ...:-' Al ‘JCL'ot % ..-, Lot Exp Date Vac Name _...,„ Lot # Lot Exp Date
VACCINE/TEST 4WKS 1YR PRICE VACNNE /TEST 4WKS 1YR PRICE
.0 5 in 1 (DA2HPPV) W LH RH 0 5 in 1 (DA2H V) W LH RH
0 Corona 0 Lepto W LH RH 0 Corona 0L to w LH RH
0 Bordetella I N W LH RH 0 Bordetella I N W LH RH
0 Lyme W LH RH 0 Lyme \ W LH RH
0 4DX Snap: HW Pos Nag Lyme Pos Neg 0 4DX Snap: HW Pos Neg yme Poe Nag
Ana Pos Neg Ed Pos Nag Ana Pos Neg W ,Pos Nag
0 0 i
0 FVRCP W LH RH 0 FVRCP W\01,t i RH
0 FeLV 0 VetJet W LH RH 0 FeLV 0 VetJet W L
0 Feline Triple Test: 0 Feline Triple Test:
FeLV Pos Nag FIV Pos Nag HW Poe Neg FeLV Poe Nag FIV Pos Neg HW Pos Nag \ RH
0 Fecal Test Pos Neg 0 Fecal Test Poe Neg \
0 Strongid T ml 0 Strongid T ml
0 Droncit ml W LH RH 0 Droncit ml W LH RH
Biomedical Waste Fee Required 4- 0 Biomedical Waste Fee Required
0 Microchip # . 0 Microchip #
0 Write in Heartworm Meds and Comfortis Here 0 Write in Heartworm Meds and Comforts Here
Rx / Services Sub-Total $ RX / Services Sub-Total
Products Sub-Total $ Products Sub-Total $
:omments: Comments:
• (5/1
# 6 7--,1
Rx / SERVICES Total
CASH CK#
PRODUCTS Total
1, MasterCard Visa Discover
Veterinarian Name , t. _ 1 f PRODUCTS Tax
1 K- 1,"' ' ,..• - Coupon LICENSE Total
Lic# Date:
Cashier \ , BIO HAZARD Total ---
Signature ..-
Receipt# L: TOTAL $ / 5--.'"-
RABIES VACCINATION CERTIFICATE Tag fee $:
ADAPTED NASPHV FORM 51 Tag #:
Owner's Name & Address PRINT - use ball point pen or type Cert. Serial #:
PRINT ST / FIRST ii, rvt , 2 TrPhiONE r
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SPECIES: SEX: AGE: SI : PREDOMINANT BREED: COLORS:
Dog X Male K 3 Mo. to 12 Mo. 0 Under 20 lbs. JY X, A ie- ,p rk.et lt, 48 elk—
Cat ' Female 0 12 Mo. or older X 20 - 50 lbs 0 - - ' NI/ -- -
Other 0 Altered 0 Over 50 lbs. El NAME:
(Specify)
DATE VACCINATED: PRODUCER: Veterinarian's # CliSi 0
tb f(c. (3 0 E---: License No.
Month Day Year (First 3 Letters) Veterinarian's
rig
1 yr. Lic./Vacc.y6 Signature 4 ? a r \
VACCINATION EXPIRES:
3 yr. LIc.Nacc. 0 Address
Month Day Year
Vacc. Serial (Lot) No.
VAC0410001
VETERINARY CLINIC OWNER OF ANIMAL
Cornerstone Animal Hospital Bonnie Yarnell
1663 East Ray Road 5193 S.158th St
Gilbert, AZ 85296 Gilbert, AZ 85298
480-857-9229 County:
This is to certify...
THAT I HAVE VACCINATED THE ANIMAL DESCRIBED BELOW.
Patient information...
PATIENT: Racquel Welsh TAG NO: 18197B
SPECIES: Canine WEIGHT: 0.00
SEX: Female AGE: 15M
Color and markings: Tan
Signed
Daniel Burke, D.V.M. License:
Vaccinations done...
10/22/2013 DB Rabies Canine, 3yr, #18197B
10/21/2016