EAST VALLEY RESCUE.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 %fp, Renewal Permit # --
Name: Lirtdi S 11 '; u-e Kennel Name: ri.75+
Mailing Address: ‘611 44.\ Kennel Location: itlkjil-Aft/Q
City 1)(1_sc,k , AZ ZIP 7r-nit County Supervisorial District
Home Phone: 1-41 %.? 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 fora 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
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./,4 I/We 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.
certify that I/We have dogs and that the kennel meets the definition in statute.
r
YNVe certify that I/VVe 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.)
INVe certify that all dogs over the age of three (3) months that are kept, harbored or maintained on the
premises of the above named kennel have been properly vaccinated against rabies by a veterinarian licensed to
practice in the state of Arizona and that a current vaccination certificate signed by a licensed veterinarian is
maintained on the premises for each dog.
?4 I /We certify that I/VVe are submitting a valid copy of the rabies vaccination certificate for each
dog with this application.

7. (---"yjseiWe 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.
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.
9-----(7,..4 1/VVe understand that a person who knowingly fails to obtain a kennel permit within thirty days after
written notification from the county enforcement agent is guilty of a class 2 misdemeanor.
this kennel permit being obtained for the purposes of operating a business including but nopimited to
breeders, groomers or boarding establishments? (Please check one) YES
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.
1(0571INVe certify that the kennel permit is being used solely for the purpose of licensing my own multiple
companion dogs in my household.
I/We certify that all of the information I/We have provided is true and accurate under penalty of law.
Applicant Signatt_O - 2 Date: — /3
Applicant Signatu(e 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.bov
Receipt Number: R13-173600 Receipt Date: 09/08/2013
Person ID: P0858375
Phone: 480 9845960
E VALLEY RESCU KENNELS
8125 E 5TH AVE 9/8/2013 3:31:50PM
MESA, AZ 85208
Item: Animal ID: Reference No: Price: Each: Amount:
KEN PERMIT A7777777 K14-000009 $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
shawcrof EBUSOFF

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- 3 Other no. use 20 letters)
El ksi Ai_ f (First Lic./Vacc. Lic./Vacc. `-.51 - CI fX1 F 3 Other no.
Print mo older (lot) Print (First Lic./Vacc. Lic./Vacc. Lor-)-7
fril)--e 12 Age_ yr. yr. Serial mo older Agetr',,.,)__\/',_ f (lot)
RABIES to or 1 3 c.gi-:/i 12 or yr. yr. Serial
ill mo mo Actual Producer: 0 V Vacc. RABIES to mo 1 3 D-
ts Age: 3 12 Age: mo Actual Producer: CI 0 6 Vacc.
1 I 3 12
Address of 0 0
Address Di 11:1
EXPIRED:
Curt and n Female Neutered -Year Year COPY and Street (3 EXPIRED:
7reelE2 Sex: Male VACCINATED: Female Neutered Year IL, Year
OWNER'S Name Day Dil Day Name Sex: Male VACCINATED:
- SO ID El VACCINATION OWNER'S Last ti El 0 '1)0 Day Yii Day
Owner's PRINT . Species: Dog Cat Other: (specify) DATE Month .? Month Owner's - Species: VACCINATION
PRINT o. Dog Cat Other: (Specify) DATE 1 Month / Month
OWNER' S rOPY RABIES VACCINATION CERTIFICATE
NASPHV Form #51 Rabies Tag Number
Owner's Name and Address Print - use ball point pen or type
PRINT - Laq.„ , First Ml . Telephone
9lN I . _ or _i t,. L rnotc, c q -6to
No. .).4treet E. 51 (---kv-e- City 'r
Age: Size:
Male 3 ma to 12 ma Under 20 lbs.
Female 12 moor oldr 20 - 50 lbs. 0 _ .
Neutered AriP Over 50As. El
Actual - 1 lbs . Name: .
L 1 )
0 -I > < > .2 > rs7 8 c a. n ..) —n c--\
m _
LI 1Q•-) st 3 letters)
K o = 5- o ai Vacc . (Signature)
Address:
< > 0 0 2 > 0 z x -13 55 m F? Dther Vacc. 3)-5 E- 15-11-‘
. / --• ........: — rT2-
1 4-7
K n E 0 o 2,-) o . a) lm

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Number tI1JLL N',41/ 2---- *--r--.7":"" Number '"/
Colors: Colors:
Tag \ '; 10 • 14-7 511-15 IRi,75)?
. Tag -C.
Rabiei Telphone No ) (..er.‘:i{,-- 6 • Rabies Telephone .4 ci2)4i.
-L t I.) ' No.)
Sta.: 1 1 (License 1 i f)-t
M.I. Breed: 1‘,..( i-,•-• !-- I . • (License
A # _7‘," rD M . Breed: # ,, 3;Y:j
, : 1(.. . .
CERTIFICATE Predominant Veterinarian's: 7 ,_...)." CERriFICATE
type p Namr: (SignZa:r Address:, type Predominant - Veterinarian's: 77 A
or 31) s—A (Signature) Address:
or
#51 pen lbs.1 0 0 lbs. 151 pen - 1:1 17=1
Form point a , \ 0 lbs.P1 lbs
City 20 lbs. 51:klbs. -1 Form point L lbs. lbs. 1.,.(7
ball First 50 1-1 1 First City 20 50 50
VAICCHATION NASPHV use Size: Under 20 - Over Acd.ial letters) ( VACCIVATIOV NASFI-IV ball Size: Under - Over Actual
- Ig F. 3 iciVacc. Other 17.---? ) no. use 20 letters)
^int I=1 Ni i (First Lic./Vacc. (lot) nt - 3 Lic./Vacc. Lic./Vacc. Other no.
rno older i p L .?L/ . Pi ma oyei-V6 (First t (lot)
IES 12 or Agel yr. yr. ' Serial 12 Age yr. yr. '
to mo Producer: 0 1 k 3 C---) ,. ..)::. RIBES to or 1 • Serial
IFIA Age: mo 12 Actual t7acc. mo mo Actual Producer: El [43
3 Age: 3 12 Wm.
Address 0 X, 1St Address J:g El
-, '? EXPIRED: li) EXPIRED:
and Stpeet Female Neutered 1 Year I Year and Street:— Female Neutered IL;
Sex: Male VACCINATED: Sex: Male Year Year
Name Lat. 3C1 Day "VI Day Name Last VACCINATED. I
- '.jii, CI 0 VACCINATION C] 0 Day ;Y: Day
Owner's PRINT No..-/ Species: Other: (Specify) DATE .i Month Month Owner's PRINT- ?A Species: ,N VACCINATION
Dog Cat No. Dog Cat Other: (Specify) DATE Month Month
EXPIRED: VACCINATION
>-
VACCINATED: DATE
a) 0) Ta (1)
0 (NI DD LL
0 0 E C') o al 2
a) co
cr,
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Number Tag Rabies I Name Owner's

iipt:
4,„..., y
Number Colors: 1-e 151 Number -P1)3c1-11,41)6 ti.ki
V -ti if/— Colors: NaCte-- -7--- 6,1-i0
Tag 61 bo fa Tag 1-')
Rabies Telephone IT' .) 1 Rabies Telephone Fit- rt, ) o /
LM I le Statefii ) Al
(License 1 (license
M.I. Breed: # S iffietpt- M.I. Breed: j`
le # On
po„.41/ FY124rk .-r,p,
CERTIFICATE Predominant Veterinarian's: CERTIFICATE Predominant POC.a ( Veterinarian's: '
type Name: (Signature) Address: type ebok Narnt)-5 ... ii)41/ (Signature) Address:
or Liaata, or
#51 pen ili] CI CI lbs. #51 pen c rtota ryel 0 0
Form lbs. _? Form lbs.0 . lbs.
p t 20 lbs. 50dDs. I point First„ Li City 20 lbs.
VACCINATION NASPHV all ball Firs City Size: Under 50 - Over Actual .1.-- 1 VACCINATION NASPHV ball Under 50 - 501 Actual I
use 20 letters) use Size: 20 Over letters)
- El j)4 3 (First Lic./Vacc. Lic./Vacc. Other a'Z'LA7'11 no. - CI 1:6 i p- 3 Lic./Vacc. Lic./Vacc. Other 9ii1i no.
Print mo older Agest p1 (lot) Print mo 5y p (First (lot)
12 or yr. yr. 3 Serial 12 older or Age yr. yr. Serial
RABIES 1 to mo mo Actual Producer: K 1 El _::5 Vacc. RABIES to mo Producer: 1 0 gi 3
Age: 3 12 19 Age: mo 3 12 Actual Woo.
Address R El 0 Address \re, • t$1. •
COPY and Female Neutered 13 Year EXPIRED: () Year COPY and s 1 Street Neutered / .2, Year EXPIRED: IV Year
y.:3treet Sex: Male VACCINATED: Sh Sex: Male Female VACCINATED:
)WNER'S Name Last i ,ir 0 El '30 Day ')-41 Day OWNER'S Name Last 0 0 ?-)0 Day Day
c±, VACCINATION - VACCINATION
Owner's PRINT- . Species: Dog Cat Other: (Specify) DATE _l_ Month 21 Month Owner's PRINT Species: Dog Other: (SPecIfY) DATE 7 Month -1 Month
No Cat
9,83NMO Ad00
cn a
CD 0 ET- )51
D
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C.)
NOLLVNIOOVA :Cl3ildX3

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, ) , i Number ( - de
Number. :-4 ' (-• Colors:
, 7---.Ji/ Colors: rot;L:n
Zip. . ,.:2„,.19 „_..(---.1,' Tag __f)t,aCk -:e.-_.)—
Tag CV :511.1. )..6 - '
Telephone ? t- 1 ( , Rabies Telephone ,'(- 7 No-) . }-1?
Rabies L-1.7C ., , - i ?C 'Nlo,5 1 ,,,,.-2 flt_. • -
I _ f Sta
Stat 1 t (License F. e (License f'• 1,A,
M.I. Breed: ( '
M.I. Breed: !UV>: rif) .../1,%/.. L #
Li. # ' tc,-,-1
5;) i
1 Xi I CERTIFICATE R,`,Aki Veterinarian's: .
CERTIFICATE Predominant Veterinarian's: type Predominant
type --Pcor (; (Signature) Name: ‘/?'' (Signature) Address:
GI\ Name: Address: or
or , 1151 ,
#51 . pen Lo.. _ i 0 El lbs.
per 'fl-Ci. V 0 0 lbs . in lbs.Vi
. lbs. Form point . 1 lbs.
Form point i y . lbs. lbs. —L. City 20 lbs. 1.12
City 20 50 ball First -50 50 -id
ball First 50 VACCINATION NASPI-IV Size: Under Over Actual I
VACCINATION NASPHI/ Size: Under - Over Actual 1 use 20 letters) 1
use 20 letters) - F 3 c Other - no.
- F 3 Vacc. Other ,=3---7) no. 0 N \/ (First Lic./Vacc. Lic.ac. /V
• CI I %-/ / (Fitst Lic./Vacc. Print mo I) "21--14:7-3 (lot)
Print -(-- mo older Agek..'?_,__ Lc./ (lot) older Age_)_
12 ' yr. yr. Serial
____42... 12 or yr. yr. Serial to moor 1 3
RABIES to 1 3 c-,)1- RABIES mo Producer I: g c-,-.
mo mo Actual Producer: CI gi Age: 12 Actual Vacc.
. 4•=,- Age: 12 Vacc. . 3
3 i ,__.
Address 0 ck] El
Address . D A .1=1 C3hoLy_j_1 EXPIRED:
!,---• EXPIRED: and q Stree,t_ Neutered Year t,.; Year
and , 'Street Female Neutered 3 1 Year it4', Year ' Sex: Male Female
CT) Sex: Male VACCINATED: Name Last ... VACCINATED:
Name Last '.))l.) - 51 El 0 Day ,-).(1 Day
- :) K El El Day ,9-'"I Day ,..). VACCINATION
) i VACCINATION Owner's PRINT Species: Other: (Specify) DATE Month Month
Owner's PRINT . Species: Other: (Specify) DATE 7 Month 7 Month No. Dog Cat •7
N Dog Cat
. 0 c 17,- 0 •„=_.. ics. cn°5 o ce > rg., 't 2
lerryie., • ,J C T • rij
D-7 c"; -2 7 a
7 0 6 II, a Z z a >
> o :11 5.,
Address: 6 o as > --, c3 •21 . >- .c o 2
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1 Y; c'') ,i- Ie. •=- .— • r'-•
--A GI_ m 2 a ill I— .(2 < > o
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Name: lbs. l Actua
El lbs. 50 Over Ace 12i Ant —P!1 Neutered
Ibs. 50 - 20 older or mo 12 , , D Female
El lbs. 20 Under mo 12 to ma 3 Male
Size: Sex: ;
1-17 i
zipo Sta,te City I Street. No.
-500 -cl.)4-1 30 1-1, I(\c-ICA k__ e , I I C
Telephone l. M ) First Last - PRINT
type or pen point ball use - Print Address nd a Name 's Owner
Number Tag Rabies 1 #5 Form NASPHV
CERTIFICAIL VACCINATION RABIES

I, 21 i iti)6t
el - 4
Number -i)' Number ,'- ,/
Colors: ) Colors: i- /../ CA-
Tag .. Tag 617,(1 , ..--.
' 7( (,1,-/L1 /1--) ._
Rabies No.), /";;! Rabies Telephone --) C, .,_,.., 1 14-344--
WO' 7., 1 '
(License Stal Nc-.1 ,
I ,L. E..-
M.I. Breed: # ._.., M.I. Breed: C , -,„
. 3t) I t l...0 I # / , ,, - "Ci,lipC
4 72--)Y--->
CERTIFICATE L CERTIFICATE '<;
type Predominant Veterinarian's: Z-T Predominant pa Veterinarian's: L, -V -
Name: (Signature) Address: type
or or Name: (signature) Address:
#51 pen V] LI #51 pen 1_-_-_, ,
Form I lbs. Form ,,--x lbs.0 El D lbs.
point L. City 20 lbs. lbs c: point lbs.
Firit 50 50 First City 20 50,1bs. 1--)
VACCINATION NASPHV ball _ Size: Under - Actual VACCINATION NASPHV ball 50
use 20 Over letters) 01 use Size: Under - Over Actual
- f:=1 \ 3 no. - 20 letters) I
Print faLr (First Lic./Vacc. Lic./Vacc. (lot) .,.. ID Ty F. 3 Other -7 no.
mo older Other Print , (First Lic./Vacc. Lic./Vacc. ..._)
12 yr. yr. mo oldes ,r) r 47 (lot)
to or Age 1 3 Serial ,...-‘ 12 or Age yr. yr. i1 ,
RABIES mo mo Actual El RABIES I to mo 1 3 1_,8--:/ Serial
Age: 3 12 Vacc. Li -- , ) Age: mo Actual Producer: D R .....)-
c 3 12 (--- Vacc.
Address El LI Address gil, 0
LY-c L.--- , II
EXPIRED: ,
and Female Neutered -7) Year Year and 1 Streeti— --) '..) EXPIRED:
Sex: Male VACCINATED: 7 Sex: Male Female Neutered Year J4-'-) Year
Name Last L Day Day Name Last 5h Li` VACCINATED: VACCINATED: •-.. )
- V ID LI VACCINATION - Ls. pi. El El c Day ( Day
Owner's PRINT Species: Cat Other: (Specify) DATE 7 Month 7 Month Owner's PRINT Species: 3 VACCINATION ._:4•4.
Dog - . Dog Cat Other: (Specify) DATE • Month Month
-7-
no. (lot) Serial Vacc. ,,, td CI c O 2
- rt, C"
F:?(/'‘ 11:— IF.; )ther
Vacc. to iii cc z 0 F_- < Z 5 ,-t) >
Address:
(Signattl-re) Vacc.
, ra -E.
letters) 3 g -1 - nr.)°
,
\---\ LL ci) 7 2 a_ 0
z (.3 < > Ill 0
ITY-K f?
Name: lbs. Actuali;
El lbs. 50, Over Ace Actual Neutered I
-- E lbs. 50 - 20 older, or mo 12 Di Female
on lbs. 20 Under 0 me 12 to mo 3 Male
U,1 Size: Age: Sex:
24.t" N State I‘ "&. < I 1)-E3 1 '7,
l' ..... i 37 ra.61 City 1 , Street No.
(it) r _ l. M L4 1
type or pen point st ball Fir use - Print , Last - PRINT
Number Tag Rabies 1 #5 Form NASPHV Address and Name Owner's
CERTIFICATE VACCINATION RABIES

OWNER'S COPY RABIES VACCINATION CERTIFICATE
NASPHV Form #51 Rabies Tag Number
Owner's Name and Address Print - use ball point pen or type
PRINT - Last • First . M.I. Telephone
I( Ye_ it /316e_ LI t-Y:10 Le ..kiel-i -5---1Cck
No S t City State
rne.,,SCk 02. f-ki?C'S
Species: Sex: Age: Size: Predominant Breed: Colors:
Dog pil Male 0 3 mo to 12 mo El Under 20 lbs. kl \
Cat 0 Female til 12 mo or older 1,8) 20 - 50 lbs. 0 PCA-I te Pjfir i cot
Other: El Neutered 0 Actual Age 1 Over 50 lbs. 0
(Specify) i Actual 9 lbs Name:
CDC° N r-A
(Ci I
DATE VACCINATED: Producer: p F T. Veterinarian's: # i J
(License No.) :7
`-/ 3o i (First 3 letters) A
,Acr j'
Month Day Year signarure)
tin yr. Lic./Vacc.
0 3 yr. Lic./Vacc. Address: E len- -t-
VACCINATION EXPIRED: &..)..)
Other
1 c21-9 I 4 E.) , -7)t-1 9-7 1 --RP-I rc- PO Z5D=F I
Month Day Year Vacc. Serial (lot) no.
RABIES VACCINATION CERTIFICATE
OWNER'S COPY Rabies Tag Number
NASPHV Form #51
Owner's Name and Address Print - use ball point pen or type
First M.I. Telephone
PRINT - Last _ tiqo-ciet-Ftho
5h , ve If i Lund statz4z_ 1153cy
No. ... . - _.., Street_ City I 's" -VA )
(6 I -P.
Size: Predominant Breed: Colors:
Species: . Sex: Age: 5;1 Ped
Dog xi Male 0 3 mo to 12 mo • I Under 20 lbs. Pc-00 1 e
Cat MI Female tal 12 mo or older it 20 - 50 lbs. 0
Other: 0 Neutered • Actual Age _L Over 50 lbs. • Name:
(Specify) Actual_lbs
p F 5 Veterinarian's: # 1 . NCI , - A . . Z
DATE VACCINATED: Producer: kUcense No.)
II) ,
7 '() i' (First 3 letters) / „(),J.
(Signature)
Month Day Year % 1 yr. Lic./Vacc. Address:
• 3 yr. Lic./Vacc. . -,, CO-
VACCINATION EXPIRED: Other . 3'
I
1 A ilA S . . )-1
Month Day Year Vacc. Serial (lot) no.