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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 El New )ik Renewal Permit # K14- 00'7 Name: Ve c-‘ I Kennel Name: 0.1,k vin_S Mailing Address: 111r? ti Ij. s L Kennel Location: 6S-7 5 I/ Ila S Lic-1 City Cha ROI t , AZ ZIP gsa_14 8/ County Supervisorial District I. Home Phone: Ifkv-g- a---1- 02(..p7 Kennel Phone: q(S1 62 ,7 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.‘ 4vtiu I/We assume complete responsibility for the kennel at the premises for which I/we are making aplification 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- 100j). , 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, Jtv-i I/We certify that I/We have Li dogs and that the kennel meets the definition in statute. 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 )eaOh laws DO NOT apply.) 5,9"ir 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 mai9tOned 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. 7. z71 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. INVe understand that a person who fails to obtain a kennel permit under ARS 11-1009 is subject to a penalty of/twenty-frve dollars in addition to the annual fee. 9.s<r I/We understand that a person who knowingly fails to obtain a kennel permit within thirty days after writtein notification from the county enforcement agent is guilty of a class 2 misdemeanor. Is this kennel permit being obtained for the purposes of operating a business including b t ppt limited to breeders, groomers or boarding establishments? (Please check one) 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 9nswer to question 10. above is "NO" please answer question 11. 11 I/VVe 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 informa n UWe have provided is true and accurate under penalty of law. Applicant Signatur ,,4frr7-7 Date: 2v0)' 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 Maricopa County Animal Care and Control 2500 S. 27th Avenue Phoenix, AZ 85009-6797 (602) 506-7387 http://pets.maricopa.qov Receipt Number: R13-203526 Receipt Date: 10/23/2013 Person ID: P0999721 Phone: 480 8210267 WILLIAMS KENNELS 1687 S VILLAS LN 10/23/2013 2:46:25P1\ CHANDLER, AZ 85248 Item: Animal ID: Reference No: Price: Each: Amount: KEN PERMIT A7777777 K14-000007 $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: Animal# Vacc Date: Vacc Expires: Please retain this receipt with your pet's records KJENSEN 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 1A4-/-11C1/117 &cirL) iii-0-/D-1- (7-1•47 No. St t -' City A .2State ffs.ax Zip /1 Species: Sex: Age: Size: Predominant Breed: Colors: Dog • Male 0 3 mo to 12 mo 0 Under 20 lbs. 724-, 1 / /49aAAJM. Cat Female X 12 mo or older171 20 - 50 lbs. 0 Other: E) Neutered El Actual Age / 0K Over 50 lbs. 0 (Specify) Actual_ALlbs Name: ri DATE VACCINATED: Producer: i v Veterinarian's: # ak-0// 4c: / F (License No.) , --/-- 7 .-i... Jo .)--) 6 (First 3 letters) 7; "I Cr--N , / Month Day Year 0 1 yr. Lic./Vacc. (Signature) Address: 3,j.' E . -,.. / s: d Ft, 1X3 yr. Lic./Vacc. VACCINATION EXPIRED: Other An-rs-2-v 7 ..0-7-72-Cy /Q ;L? / 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 1/14/1)aJTS DeCi. Vc '17;,-/ -0.1-‘ 7 No. i .a.treet 1,.. .(1L at. City (LAI yate Zip / 1' ii- .2-,7-‘ Species: Sex: , i Age: Size: Predominant Breed: Colors: Dog 'Egt Male 0\ 3 mo to 12 mo 0 Under 20 lbs:1% Cat 0 Female 0 12 mo or older t7‘ 20 - 50 lbs. 0 Other: 0 Neutered 0 Actual Age Over 50 lbs 0 (Specify) ActuaLilbs Namfr / J d 414 . DATE VACCINATED: Producer: Veterinarian's: # A2_54177 F / (License No.) ; i b ..i) 13 (First 3 letters) Month Day Year (Signature) a., - j<7:-.. ( - ) J ,./•?*e 0 1 yr. Lic./Vacc. pC,3 yr. Lic./Vacc. Address: VACCINATION EXPIRED: Other , PO 2.1 ,g 71 Month Day Year Vacc. Serial (lot) no. OWNER'S COPY RABIES VACCINATION CERTIFICATE NASPHV Form #51 Rabies Tag Number Owner's Nameand Address Print - use ball point pen or type PRINT - Last , ,. First M.I. Telephone LiVal 6 ii-j- 19Ay 910-i-D-k-ca‘ '7 No. ,, 4tregla ...), , ) City / _ /Rate Zip i od".. / r;*- V) zzas ilLA P Species: Sex: Age: Size: Predominant Breed: Colors: Dog 0 Male El 3 mo to 12 mo 0 Under 20 lbs. IElI diu 6i1AC Cat CI Female 0 12 mo or older El 20 - 50 lbs. El alc.A. ck. Other: El Neutered 0 Actual Age Over 50 lbs. I=1 (Specify) Actual_lbs Name: 1 f.)Z.LA C i i DATE VACCINATED: Producer: ? Veterinarian's: # A 2- • i I 0 1 P F i (License No.) /D .2/ 13 (First 3 letters) Month Day Year 1. 1 yr. Lic./Vacc. (Signature) 3.)__5- E-0 ir-7,2( Address: CA yr. Lic./Vacc. VACCINATION EXPIRED: Other r--- .4) . 71-7-Pei . .--Gr-3 /0 --Z) / 6 .24,----, 4 5- 7 ) Month Day Year Vacc. Serial (lot) no. OWNER'S COPY RABIES VACCINATION CERTIFICATE Owner's Name and Address NASPHV Form #51 Rabies Tag Number PRINT - Last Print - use ball point pen or type First M.I. Telephone 04/Z/I r /7/1e0.) No. Strefit, / iisr ,t- v City c_hparte A),$y2 iiet.r i,AA Species: Sex: Age: Size: Dog -OE, Male IA 3 mo to 12 mo El . Predominant Breed: olors: Cat ED Female 1=11 12 mo or older rif Under 20 lbs.PR 7" i ' ''/, / ,40 6./t4i-te Other: 1:1 20 - 50 lbs. CI ''' - —I-- - (specify) Neutered El Actual Age Over 50 lbs. El Actual 3 lbs. Name: r----/ DATE VACCINATED: ,/ Producer: roducer: Veterinarian's: # Jo .2_1 /2 / (Zile No.) (First 3 letters) Month Day Year CI 1 yr. Lic./Vacc. (signature) VACCINATION EXPIRED: 3 yr. Lic./Vacc. Address: 315 E Ics--.71./ yr_ Other ..---7 o 2, 16 y 5- 7j 4,-7; Month Day Year V cc. Serial (lot) no. OWNER'S COPY RABIES VACCINATION Owner's Name and Address NASPHV Form #51 CERTIFICATE PRINT - Last , • Print - use ball point pen or type Rabies Tag Number First No. 1 ( 6 ckiStreet LO1 — I i 16,r111S Tex M.I. qw. Telephon e r i t , Species: 5 . V k ' I \ C6 I '1 State Sex: Age: City CIrW\d[J2K 2_ Dog X Male 0 Size: * Cat CI Female 3 mo to 12 mo 0 Under 20 lbs. X Predominant Breed: Colors: Other: CI Vii, 12 mo or older Tici 20 - 50 0 , - i (Specify) Neutered 0 Actual Age 1:2 y lbs. E 011 irtiojAtAcA blonAe Over 50 lbs. 0 Actual Actual & -D lbs. Name: DATE VACCINATED: • 'blond, i-e Producer: CI 1 0 1) -T' - Veterinarian's: # i 1 ZC1 riZ. Month Day (First 3 letters) (License No.) Year A 1/"..... --... .,, 0 1 yr. Lic./Vacc. (Signature) v VACCINATION EXPIRED: X 3 yr. Lic./Vacc. Address: Other :715 E 1 6,--A-,. 5.4 Month Day Year 17113),q. Vacc. Serial (lot) no. -Tep-r- ra--1 54 1 )WNER'S CCP' RABIES VACCINATION CERTIFICATE Owner's Name and Address Print NASPHV Form #51 Rabies Tag Number PRINT - Last - use ball point pen or type , First A IICLI(1 M.I. Telephone No. ' 1Ley7 Street „ T --1e V i t 10,S 1. T\ City State LIF)0— 64- Al Species: Sex: Arlo nci 1 C-17 ic12_, Dog gc Male Age: Size: Predominant *St49 Cat 0 3 mo to 12 mo 0 Under 20 lbs. X Breed: Colors: 0 Female 21. 12 mo or older Ul 20 - 50 lbs. 0 i, ibvia_ (Specify) Other: 0 Neutered 0 Actual Age IA y Over 50 lbs. 0 -Tan Actual ,'1 D lbs . Name: DATE VACCINATED: ritirfAIV Producer: p 11 F__ q ID I D Veterinarian's: ......,,pcense # l?Cii PO_ (First 3 letters) o.) Month Day Year 0 1 yr. Lic./Vacc. (Signature) ' VACCINATION EXPIRED: X 3 yr. Lic./Vacc. Address: q ot b Other ff Si---i A Month Day Year Vacc. Serial (lot) no. Tole- 6Z-- "3 5'478 i 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 --,-- WI i ' arl(15 I -e..,:( Y 1E 1-1V —20 i— 0.1111 Noitv.wi Seel v 1 1 [ A. City State Zip C.-kr,t/CL if, 'Pe -ZSD-F4P Species: Sex: Age: Size: Predominant Breed: Colors: Dog Male CI 3 mo to 12 ma CI Under 20 lbs. ID Cat [I] Female X 12 mo or olde r it 20 - 50 lbs. C nt 0 Other: 0 Neutered E Actual Age 1 y Over 50 lbs. CI (Specify) Actual 50 lbs Name: Pe.adie-E) . DATE VACCINATED: Producer: p F. Veterinarian's: # ) i'.3 1 AZ (License No.) d . 61 1 0 1 ) (First 3 letters) Month Day Year (Signature) di/ 1 0 1 yr. Lic./Vacc. X 3 yr. Lic./Vacc. Address: VACCINATION EXPIRED: EXPIRED: Other 3)6 01 Ci 1( E)17151'? A -Tery,r, pt-L-75g] Month Day Year Vacc. Serial (lot) no. OWNER'S COPY RABIES VACCINATION CERTIFICATE Owner's Name and Address NASPHV Form #51 Rabies Tag Number Print - use ball point pen or type PRINT - Last First M.I. Telephone ( , t i I . ' 1 i I' ciay--6 T& - I t No. Street- In- _.)( - OX1 11P 'b-7 City State Species: Sex: Ci-arkeii-r- 62, I If.5 A IQ Age: Size: Predominant Breed: Colors: Dog X Male E 3 mo to 12 mo E Under 20 lbs. Cat CI Female N. 12 mo or older [k 20 - 50 lbs. 0 l ' h I nuahuk -G-r-Cian3----- (Specify) Other: 0 Neutered CI Actual Age Over 50 lbs. CI Actual _4_ lbs. Name: C 0(OCk DATE VACCINATED: Producer: Veterinarian's: # 1 I -Yi PR -17 -1 (License N..) 0 _i (First 3 letters) Month Day Year 1:1 1 yr. Lic./Vacc. (Signature) VACCINATION EXPIRED: Ai 3 yr. Lic./ Vacc. Address: Other :3J6 f If"-K- S+ 9 9 IS S1-115rbq Terylft_ --A-1 -zni Month Day Year Vacc. Serial (lot) no. OWNER'S COPY RABIES VACCINATION CERTIFICATE Owner's Name and Address NASPHV Form #51 Rabies Tag Number Print - use ball point pen or type PRINT - Last . First M.I. Telephone ki r,tvi Z/27-el." No. /c-r treet iji,/,16,, /AA City(446 A State , 2-4 Species: Sex: Age: Size: Predominant / Breed: Dog Male -1K 3 ma to 12 ma CI Under 20 lbs-.. r, Colors: Cat Female El 12 mo or older 20 - 50 lbs. Other: 0 Neutered CI Actual Age , Over 50 lbs. 0 (Specify) 9Vir Actual lbs. Name: , le-/C)(5-7rei DATE VACCINATED: Producer: f F. i 1 Veterinarian's: # 1. i i P- 7 (cense No ti T _)_ )1 (First 3 letters) Month Day Year (S1gnat7) e El 1 yr. Lic./Vacc. LF4 3 yr. Lic./Vacc. Address: VACCINATION EXPIRED: EXPIRED: Other 7.2--? ill I°5 Month Day Year Vacc. Serial (lot) no. OWNER'S COPY RABIES VACCINATION CERTIFICATE Owner's Name and Address NASPHV Form #51 Rabies Tag Number , PRINT - Last Print - use ball point pen or type „ First M.I. Telephone k.) ) I 1 I afftS I -exi re_ No. Street— . ,- - , . City 1-1S1)-P1-6x2 I U):F1 CD - v Inas L. atrvuld i.e_Y Statepta Species: . Sex: Age: Size: Dog Al Male Ci 3 mo to 12 mo CI Under 20 lbs. tki Predominant Breed: Colors: Cat 1:1 Female X 12 mo or older g 20 - 50 lbs. El 0,,,r\i,t,,kt.i.6t ' i bock_ (Specify) Other: El Neutered CI Actual Age _4 Over 50 lbs. [1 ape: Actual_a_lbs oki.,, — 1),i- DATE VACCINATED: Producer: p p 11 Veterinarian's: # I 121 AZ (License No.) GI i 0 0 (First 3 letters) Month Day Year /.4 / / CI 1 yr. Lic./Vacc. (Sign tkriP(1 1:e1"' (—).- W 3 yr. LiciVacc. Address: VACCINATION EXPIRED: Other Ci 916 $ 17 1 6jZ A ,,r_i_ R, 236).:it I Month Day Year Vacc. Serial (lot) no. 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.I. Telephone No. ) t etreilee City State Zi 4/4,7411,11/2- r:OW Species: Sex: Age: Size: Predominant Breed: Colors: Dog ---/K Male CI 3 mo to 12 mo El Under 20 lbs. CI Cat CI Female --Ne 12 ma or older. 20 - 50 lbs. Other: CI Neutered DI Actual Age 9yr- Over 50 lbs. DI (Specify) Actual lbs Name: ,/ /' I/ f-.) /1-272._ DATE VACCINATED: Producer: p G Veterinarian's: # (License A.L.o»yi No.) i r .2-(--/ p (First 3 letters) Month Day Year CI 1 yr. Lic./Vacc. (signature) Address: sT:$3 yr. Lic./Vacc. AL., Kim VACCINATION EXPIRED: Other 7p.,,v2ei 4P ,z, / Month Day Year V‘;'gc--. Serial (lot) no.