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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 o 0 New at, Renewal Permit # 37 Name: Firce---5\t/NA t.k Kennel Name: [72 etic-5 t\ Mailing Address L/ 14.) (....:ete;1--iit Kennel Location: -2-) 7:3 - - / Lt 5 Pi City P ,1 , AZ ZIP Pef, County Supervisorial District .1-1 I Home Phone: L( `)' 6/- cr:r Kennel Phone: 0) — &--6(9 / C4/ -5c6-- --.6s') vs-- 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. vz 1NVe 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. 0-11- 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. 1/We certify that IANe have dogs and that the kennel meets the definition in statute. 4. ez 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 4sh laws DO NOT apply.) 5. 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 property 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. 6" I /We certify that IANe are submitting a valid copy of the rabies vaccination certificate for each dog with this application. ' 7. kA:•-- 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. Li- 8. I/We understand that a person who fails to obtain a kennel permit under ARS 11-1009 is subject to a penalty f twenty-five dollars in addition to the annual fee. 9. 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. 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) 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. 'V' I/VVe 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 INVe have provided is true and accurate under penalty of law. Applicant Signature Oka /4/2/.1 IN, Ma/It_ Date: V 3 j20/ , 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 2 of 2 Maricopa County Animal Care and Control 2500 S. 27th Avenue Phoenix, AZ 85009-6797 (602) 506-7387 http://pets.maricopa.gov Receipt Number: R13-167044 Receipt Date: 08/27/2013 Person ID: P1539572 Phone: 602 7896051 HARSHMAN KENNELS 3342 W CACTUS RD 8/27/2013 3:00:55PM PHOENIX, AZ 85029 Item: Animal ID: Reference No: Price: Each: Amount: KEN PERMIT A7777777 K14-000037 $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 APODA CAP EBUSOFF VETCCe MonM Pal Walther. • OFFICIAL VACONA11ON CERTIFICATE/RI< - CANINE 121 , 'P!473ib - 7115 16th Sheet East, Sarasota, F134243 Vetcoainics.com 1-877-838-7468 CA Store e / / Last Name Y N Sate ii ig HIH Stailaalaartrffles Name II- h i 1 I i au, Ili-, cptri 1 1 -1- 1-11 rya BOONTNITfORUIMMUNE:si • INI o lin r_MIMS 1 MN= M11111111111111 IIIII/1 ! tiowomirouHEARAsour s? • Redid Signers n Says F --) isienyt ssassa r) Vasil f Mend C , mho : I- diaPriV-J5c8HY:Htimii-e.(8iCsitzell'imnISY.4728:arra.fiveis-a -" stIA-.1i8team F.4arawmOlskaivial kir flo Comlid . 1 Sur M / F Ahmed: T j'i liariSat li /,' PIL.h • 1. 1,.. I---- _ .irr .t.: \ s ,_ I:7- _ i Sao: PA LF...JuterEd: r I tg.:, 1 , 4 tar; i fti .1f2... Mixed:Y 1 t .' , ' - ..: 4.44) _10,141, .,44r..............„_._._mixed: f Y / j _ CS Catim FatTakfil small' t ket tvoshe--A Dom 14,11; : - .1.,-.ert—i../...,' k. L weight .giirmaL42j —rot. g, i Vatierreitt YJ o ) r lE / ...• ^ _drit•-.*I6t _,,____ .. 7 v /41 ; l .on Meremtlum7 r / Pi Jkltr rd&POltn Your pet's Lifestyle Assessment. Please check all that apply to youroet. My dog.... Your pets Lifestyle Assessment. Please cheek all that apply to your pet. My dog.... 1 Has previously experienced a vaccination reaction: 0 , 1 Has previously experienced a vaccination reaction: 0 2 Needs annual vaccines: (1) 2 Needs annual vaccines: ilP 3 Is exposed to the following: 3 Is exposed to the following: 0Mosquitoes 0 Fleas 0 Ticks 0 Mosquitoes 0 Fleas 0 Ticks 0 Hiking °Wildlife 0 Children 0 Hiking 0 Wildlife 0 Children 0 Groomers 0 Boarding 0 Traveling 0 Groomers 0 Boarding 0 Traveling 4 Is on a monthly heartworm preventative: 0 V"..f.' 1:-.;" 4 is on a monthly heartworm preventative: 0 5 Is microchipped: D .---,,, . 1 5 Is microchipped: 00 NOT WRITE BELOW LINE °11(32Calogli21 i&ir 00 NOT WRITE BELOW THIS LINE • FOR OFFICIAL USE ONLY' t , p. ..„ .., ,, li.0 ',- i ri iir i. RARIFai ---ff i5 SQKllied 0 1Y ;tr, ., Bi . SC1 Killed 0 1YR V alit WS: , • 1 • i It‘ ‘ , , % t... . , To #: Mfe. Exo Da : } 1 - al In , Mf to Date: Adult Healthy Dog ® 0 ® Adult Healthy Dog 0 0 ® $ Puppy Package 0 Puppy Package 0 © ® 4wit 1yr S v, i yr MIN 3 Rabies Vaccine 0 I YR ., 3 YR I. 'Ft ...imim Rabies Vacdne 0 YR - 0 3 YR 11111 0 Bordetella Vaccine I N 5: LI: cv 0 Bordetella Vaccine . I N ' MI ME 0 DHP rytiVaf.dne ( • inOS-in-1 DA2HPPv) tv LII Ri! 0 DHP Parvo Vaecine (Canine S -io-1 DA2HPPv) 0 Lepto Vaccine 0 Lyme Vaccine w LH NH 0 Lepto Vacdne 0 Lyme Vacdne ,-, LH P4 0 HeartINC41115113P1V , ; Pox Neg IIIII Heartworm Snap TeA ,' . . '.Pos Neg 0. 4 DX Snap Test* HW P / N Lyme P / N 11111 0 4 DXSnap TestOw P / N tynii P / N Ana P / N Erl P / N Ana P / N Erl P / N II 0 H3N8 Influ 0 Rattlesnake Vacdne* w NIUE o H3NR lnflu 0 Rattlesnake Vaccine s w 1H RI MOM 0 Roundworm/Hookworm Dewormer dose .,..... III 0 Roundworm/Hookworm Dewormer dose IM M IIIII 0 Tapeworm Dewormer dose W Lil ' 0.0m 0 Tapeworm Dewormer dose 0 Other ill 0 Other MI 0 Microchip # 0 Microchip it ,_11111 1. VACCINE TOTAL Series # . 1. VACaNE TOTAL Series # PC VC*, 0 0 0 • 0 PC VC4 0 0 0 111. 5., . . u , in ReStrkted/Prescripbion Quantity REM! 5 0 Heartgard Plus 0 6 Months 0 0 ' © 0 — Heartgard Plus . 0 6 Months 0 a ,,--.•• 0 Iverhart Max Allit:Matv.a.. 0 0 0 Imbed Max '''• 1 0 ' romm • CD---411) 0 0 0 Trifexis 0 Mont OI 0 0 0 . ._ 0 'Midas \ ,• 6 Month!! 0 ID CI MI 0 Comfortis 0 6 Months ®' 0 0 0 Comfartis 0-6 Months 1 0 (21' 0 0 0 other 0 6 Months 0 0 0 0 0 Othur 0 6 Months CY 0 -0 CI . P 5 0 • A L RESTRICTED/PRESCRIPTION TOTAL $ . .... an,: - Oyealhe-Counternifflef Quantity Over-The-Counter/Other Quantity 0 Certifect 0 ' 3 Months . C) C) 0 C) 1M1 0 Certifect 0 3 Months 0 0 ® ® MI • Pet ID Card / Other MI Pet MUNI / Other =I 3. OVER-THE-COUNTER/OTHER TOTAL , 3. OVER-THE-COUNTER/OTHER TOTAL • :-Al l $ Applicable tax per state guidelines $ IIIIII Applicable tax per state gurdeimes ainillill Comments: COITIFIlellti: / 1, , -.. - - Il-c L =1111..1111111MMINIIIIMPIMM i",/,lif £.-n_ VC/MC/Discover Am Express 0 Vaaination Services 0 Renricted/Prescrimion CASH Checkft - 0 Over-the-Counter • Discount: 0 Tax $ Amount or Percentage : 0 us, Coupon Amount I ' Veterinarian Name,. • Receipt I Bin Hammel Fee .i. -. ;.(.4.) Lica Date. I- - Y+ ' Cashier ticense Fee Signature ' • IAMere Available RABIES VACCINATION CERTIFICATE Tag fee $: : . Tag #: ADAPTED NASPHV FORM 51 4 Cert. Serial #: PRINT - use ball point pen or type Owners Name & Address FIRST MI TELEPHONE. PRO,LAST 4 .... - . - i 1,, l e , 10, gic NO. STREET CITY STATE ZIP , SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS: / Dog 0 Male 0 3 Mo. to 12 Mo. 0 Under 20 lbs. 0 , c(1:4:• i _ ' Cat 0 Female 0 12 Mo. or older 13 20 - 50 lbs 0 -,./, Other 0 filtered 0 Over 50 lbs. 0 NAME: (Specify) DATE VACCINATED: PRODUCER: Veterinarian's # ) License No. -7 ) 1 ., Month Day Yeer (First 3 Letters) Veterinarian's 1 yr. UciVacc. 0 Signature _ VACCINATION EXPIRES: 3 yr. Uc.Nacc..1:i Address - , t , , 4) . I ' Month Day `fear 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 #: pRintr LAST FIRST MI TELEPHONE.- . _,..• , / -i efr•-... , 11- y —. ., .. NO: 2 EET, 1 STATE ZIP -- i - SPECIES: SEX: AGE: SIZE: PREDOMQNT BREED: COLORSrk r e-:" Dog -10 Male in 3 Mo. to 12 Mo. 0 Under 20 lbs. 0 i , i i 1 t Cat 0 Female 0 12 Mo. or older 0 20 - 50 lbs r-i La . • . :1 - Other 0 Altered 0 Over 50 lbs. 0 NAME: .., . (Specify) DATE VACCINATED: PRODUCER: ' . . _ Veterinar ian' s # License No. , - ... , Month Day Year (First 3 Letters) Vetennanan's ---- ' 1 yr. Uc.Nacc. 0 Signature VACCINATION EXPIRES: 3 yr. Uc.Nacc.,P Address —I • 1 I :A 1 .C. /- %-..,i I - . -, ',..4; I - Month Day Year V, , g Vacc. Serial (Lot) No. 10001 VACCINATION RECORD RABIES VACCINATION CERTIFICATE Tag fee $: Name ADAPTED NASPHV FORM 51 Tag #: RABIES PRINT - use ball point pen or type Cert. Serial #: El LYME DISEASE Owner's Name & Address PRINT LAST r, , FIRSTS MI TELEPHONE .4/14- El CANINE DISTEMPER Ht I? ) IN ii\ e, t-, ? ' i t,,, '-,---, I t' •,-;_.---r...`: r. 0 CANINE PARAINFLUENZA I -, , STATE ZIP - ,.. N101 .:7: il./ STREEri T. .1 1 ' . ?- +1 .. --- f, diY .-1-` i ) t. '. /7 -Z.. . ":.- kl. 'Y 0 CANINE ADENOVIRUS 2 • L.. SIZE: PREDOMINANT I3REEpi , COLORS: , • U CANINE PARVOVIRUS SPECIES: Dog -E . SEX: Male 0 AGE: 3 Mo. to 12 Mo. ID Under 20 lbs. l=1 • / ' 1 ' , i' .1- '''• • ' •' ' '' ': I - I . PI N 1 f .4' DCANINE CORONAVIRUS Cat 0 Female E 12 Mo. pr older ri 20 -50 lbs 0 0 CANINE BORDETELLA Other Ei Altered , r, • CI Over 5(1 lbs. 0 NAME: ' , LEPTOSPIROSIS (Specify) 0 FELINE LEUKEMIA VIRUS i i 0 FELINE PANLEUKOPENIA DATE VACCINATED: PRODUCER: Veterinarian's # C FELINE RHINOTRACHEITIS . ; License No. 1 . 0 FELINE CALICIVIRUS Month Day Year (First 3 Letters) Veterinarian's ID FELINE CHLAMYDIA 1 yr. Lic.Nacc. 0 Signature FELINE IMMUNODEFICIENC` VACCINATION EXPIRES: l 3 yr. Lic.Nacc. l!}. - Address VIRUS Month Day Year Vacc. Serial (Lot) No. Boehringer VINV Ingelheim VAC0410001 VACCINATION RECORD RABIES VACCINATION CERTIFICATE Tag fee $: Name ADAPTED NASPHV FORM 51 Tag #: 0 RABIES PRINT - use ball point pen or type Cert. Serial #: 0 LYME DISEASE Owner's Name & Address PRI T ST FIRST TELEPHONE 4, Cy 0 CANINE DISTEMPER 4 1 a 5•A 4 yi V 1 C A.k - 57525= o 0 CANINE PARAINFLUENZA NO. _3 3 ,-iF5 40. 64 cAit CITY — d 47( STATE Z1V6,„..v 9 D CANINE ADENOVIRUS 2 Plytl0M41 NT BCD: COLORS: . El CANINE PARVOVIRUS SPECIES: SEX: AGE: SIZE: 0 CANINE CORONAVIRUS Dog $1-- Male 45- 3 Mo. to 12 Mo. Ell Under 20 lbs. E ve....) Le4 - ()A 0-"E Cat 0 Female 0 12 Mo. or older -.1tf 20 - 50 lbs 0 5fr 41. 0 CANINE BORDETELLA Other 0 Altered io,(. Over 50 lbs. 4g NAME: LEPTOSPIROSIS (Specify) 0 FELINE LEUKEMIA VIRUS tJ t` kv.... D FELINE PANLEUKOPENIA DATE V4,CCINA D: PRODUCER: Veterinarian's # I,.,141/11 LI FELINE RHINOTRACHEITIS ., 0 i 1 . i E. 0 FELINE CALICIVIRUS Month Day Year (First 3 Letters) Veterinana 0 FELINE CHLAMYDIA 1 yr. Lic.Nacc. Sig 0 FELINE IMMUNODEFICIENC` VGDATpN 77 : 3 yr. Lic.Nacc. 0 d dress .. VIRUS wattraNis ) 1.-) ) \'L1 2' Month Day Year Vacc. Serial (Lot) No. Boehringer iIIIi Ingelheim VAC0410001 VACCINATION RECORD RABIES VACCINATION CERTIFICATE Tag fee $: Name ADAPTED NASPHV FORM 51 Tag #: Owner's Name & Address PRINT - use ball point pen or type Cert. Serial #: 0 RABIES 0 LYME DISEASE PRIVTI LAST FIRVI , , zi. TELEEFIONt E.") V (), i -e V — c26 —/ 0 CANINE DISTEMPER triale6kVACI I.\ _ 1 0 CANINE PARAINFLUENZA NO. STREET CITY STATE I 0 CANINE ADENOVIRUS 2 SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED . COLORS: *Laill 0 CANINE PARVOVIRUS 0 too 11 te N Dog IW-- Male 0 3 Mo. to 12 Mo. 0 Under 20 lbs. WI, t fr_ 0 CANINE CORONAVIRUS Cat 0 Female -g 12 Mo. or older -ig 20 - 50 lbs 9s1 LI CANINE BORDETELLA Other 0 Altered rizi Over 50 lbs. 0 NAME: 0 LEPTOSPIROSIS (Specify) 0 FELINE LEUKEMIA VIRUS k461- DATE VACCINATED: PRODUCER: 0 FELINE PANLEUKOPENIA Veterinarian's # q7 _SU ..---" License No. 0 FELINE RHINOTRACHEITIS Month Day Year (First 3 Letters) 0 FELINE CALICIVIRUS Veterinarian's _ 0 FELINE CHLAMYDIA 1 yr. Lic.Nacc. 0 Signature VACCINATION ,...c._ ci EXPIRES: i co 0 FELINE IMMUNODEFICIENU 3 yr. Lic.Nacc.y1 Address 3,--) r--- VIRUS Month Day Year Id- VC kfi Or \ Vacc. Serial (Lot) No. /-;\ • Boehringer 411) Ingelheim VAC0410001 VACCINATION RECORD RABIES VACCINATION CERTIFICATE Tag fee $: Name ADAPTED NASPHV FORM 51 Tag #: Owner's Name & Address PRINT - use ball point pen or type Cert. Serial #: 0 RABIES 0 2 0 LYME DISEASE PRiNfLAST FIRST) j, , ‘ MI TEPHLIINE 6, 11 a le 5-61,1 K I/ ( c., i L 0 CANINE DISTEMPER 0 CANINE PARAINFLUENZA NO. STREET CITY r‘ STf _ ZIP 3 -3gL2 10 C., f-64\k5 K6 1j/A 0 CANINE ADENOVIRUS 2 SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS : Riedg 0 CANINE PARVOVIRUS Dog q=3*-- Male _?... 3 Mo. to 12 Mo. 0 Under 20 lbs. 0 0 CANINE CORONAVIRUS Cat 0 Female 0 12 Mo. or older ita. 20 - 50 lbs 0 '5 rin. fl_ kli-e_ LI CANINE BORDETELLA Other 1:1 Altered .. Over 50 lbs. 0 NA h c 0 LEPTOSPIROSIS (Specify) C oy 0 FELINE LEUKEMIA VIRUS DATE VACCINATED: PRODUCER: Vete rinarian's # 4 7 .50 0 FELINE PANLEUKOPENIA q i- License No. 0 FELINE RHINOTRACHEITIS --c 30 e Month Day Year (First 3 Letters) ., 0 FELINE CALICIVIRUS Veterinarian's — 0 FELINE CHLAMYDIA 1 yr. Lic.Nacc. 0 Signature VACCINATION Li- EXPIRES: i ,c, 0 FELINE IMMUNODEFICIENCY 3 yr. Lic.Nacc. EYN Address VIRUS c-- la t 7-4,9(49 il-- \.) e, vu,„ 57c Month Day Year Vacc. Serial (Lot) No. (TA Boehringer Ingelheim VAC0410001