Extracted text (via pymupdf_layout)
17843 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 0 New y4. Renewal Permit 404- I a Name: -r1 Kennel Name: _ Mailing Address: 7(:)1 I k). Kennel Location: n b 0 1 A) City 1,0a dde 11 , AZ County Supervisorial District r Home Phone Lt (3.I Kennel Phone: (0, 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 I/We assume complete responsibility for the kennel at the premises for which I/we are making aWitation 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). 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 parmit I/We certify that I/We have 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) or13-2910.01 (dog fighting), or any other state, county or municipal animal welfare law. (Violations of license and leash laws DO NOT apply.) _______ 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 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. 7.-1/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 -1Q08 exce'pt if the dog is only being transported to another kennel which has a permit issued under this section. I/VVe understand that a person who fails to obtain a kennel permit under ARS 11-1009 is subject to a pelty of twenty-five dollars in addition to the annual fee. I/We understand that a person who knowingly fails to obtain a kennel permit within thirty days after whtten notification from the county enforcement agent is guilty of a class 2 misdemeanor. 10,t5 Is this kennel permit being obtained for the purposes of operating a bless 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: 6) 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 1-94 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/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 a I of the information INVe have provided is true and accurate under penalty of law. Applicant Signa - Date: 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.gov Receipt Number: R13-088946 Receipt Date: 05/0112013 Person ID: P7024491 Phone: 602 8711180 CLEARWATER KENNELS 7601 N 185TH AVE 5/1/2013 9:20:02AM WADDELL, AZ 85355 Item: Animal ID: Reference No: Price: Each: Amount: KEN PERMIT A7777777 K14-000012 $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: moo "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 REYNOLDS EBUSOFF IVI21.11. 1L, lip 0, IL/kJ 1.11-11Ly Animal Care & Control 2500 South 27th Avenue Phoenix, AZ 85009 Phone: (602) 506-7387 pets.marieopa.gov KENNEL PERMIT PREMISE INSPECTION APPLICANT 5 (1.50. i4ryCeison- 61:11'1,00t- STREET ADDRESS 0 I /0, I g5--4\ A-u-e__ CITY, STATE, ZIP k/00( 400..e [1 ,c s=c3.5-5-- ) 33 HOME PHONE b-sc)ac--,, BUSINESS PHONE b? COUNTY DISTRICT KENNEL LICENSE # KILI-00, NUMBER OF DOGS t Ct 1. 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 9r 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 I -7 RABIES VACCINATION CERTIFICATE - e Rabies Tag - Number . NASPHV Form #50 Owner's Name & Address bell kie_Ven or Mee PRINT - Lot.A...N.) Species: —.7=- Sttx Age: Size: VSZrecik IC( P-)Z‘613 Male I=1 3 mo. to 12mo.0 Under 20 lbe. 12 mo. Or older 20-50 bs. Over 50 lbs. U Li 1 yr. Lic.Nacc. sA15-1 (Fast 3 letters) X3 yr. Lic_Nsro: Other For Licensing Agency Uee DAZA,CCINATE_6 0 11 Veterinarian's: ' * License No. Year Month Day Year Signature CKEYEVETERNARY SERVICES, L.L.C. 24090 W. HWY 85 14— RABIES VACCINATION CERTIFICATE Rabies Tag Number NASPHV Form *SO Cwner's Name & Address Print - use bell point pen critrp PRINT - Fl tM4.61 N° Species: Sex: Age: Size: 3 mo. to 12 mo5il Under 20 lbs. 2CIrgT— 1:11 Ci ZZV ddle-14fitif rese - il 141011 .12Th mo. older 20-50 lbs. 411 . Lii ald INMAN WI.' Oyer 50 lbs. U Magi. tri1 yr. Uc.Nacc. (RIM 3 Milers) 3 yr. Lic./Veco. For Licensing Agency Use I DATE VACCINATED : Veterinarian's: I License Lice No. Year Other Change CI Add KEYEVE:TERNATIV Conbol No. 2401) W. i'lWe RABIES VACCINATION CERTIFICATE I Rabies Tag taunter NASPHV Form 050 Owner's Name & Address - usi bell Pokt Pen or him . '.. 11-M• A , CitY A Zfi139 I P 0 1 Strit) tg° A . I ff 1 1 . 1 Species: Sex: Age: Size: Breed: Dog g Male 3 mo. to 12 mo)4 Under 20 lbs. CI 1 , , • o ri , DIM& Cat r.3 F5fl5j U ...----:, . q- - 20-50 ibs. -.4 Name 9 , , • c:)...,) i ) • r 50 Ibe. ZI itaruillMisle . Prorjcer. i illiol _, 1 yr. LicJVacc. Eott6sitAZ 4 (First 3 letters) C3 3 yr. LicAraoc. Other For Licensing Agency Use DATE V CINATED Veterinarian's - 0 3-4:3 License No. Year /f 12 • _ Month Day Year lhoillitk Signature Other IL rI - TION EXeiRES: 1 A _ CKEYE VETERINARY SERVICES, LL Change L-.1 Add Ul 4- r 24090 W. HWY 85 Control No. ( cr--- ): • ,, Day Year— e ilLICKEYE, AZ 85326 C."1. RABIES VACCINATION CERTIRCATE Rabies Tag Number NASPHV From 050 Owner's/game & Address Prtitt - use betpoint pen ix type Producer 1 yr, Uc.Neoc. (Rmt 3 left* r.:11 3 yr. Lic.Naoc. Other For Licensing Agency Use DA14/ACCINA1EI D:tc.„ License No. Year Ilaayy Other Signature '*--- iliCKEYE VETERINARY SERVICES, Li Change U Add Ca Control No. 24090W. NW" Rc BUCKEYE, AZ ,.,;i326 RABIES VACCINATION CERTIFICATE iregg Nurltbbeerr Nur NASPHV Form 1150 Owner's NII/1113 & Address use bell point pen or type PRINT ei - 466 Sin fttey gattsrAtr, I:11 a Predominant Breed: Deg S"Ges )94 IC 3 mo. to 12 mo. .38 Under 20 lbs. .12 mo. or cider 20-60 lbs. 11 cod Over 50 lbs. Eir7EV slcc540.40 (14:59e t Li 1 yr. Lic./Vacc. (First 3 letiam) itiC13 yr. Lic_Nacc. Other For Licensing Agency Use ATEIvAcciwyr License No. Year Veterinarian's: Other VACCI Change ID Add LI Control No. 4-- it 1 1-Q RABIES VACCINATION CERTIFICATE Rabies Tag Number NASPHV Porn) 150 Owner's Name & Address P,bd -ussbøpokdpsnortYps Under 20 be. VI 20-50 lbs. [a Over 50 be. la For Uoensing Agency Use License No. Year rsysie Signature Other INATK)N Change la Add 1:1 IUCKEYEVETERNARY SERVICFT. 1_1.Q Control No. 24090 W. HWY CS SUCKE4E,-A85-31t RABIES VACCINATION CERTIFICATE Rabies Tag Number NASPHV EOM 150 Print -a. bell mint pen or Woe Species: Dog S± ' ski Producer: W2IFAII RE 1 yt UcJVacc. aVelgts (Rim 3 letters) 3 yr. UciVacc. Other For Licensing Agency Use DATE VACCINATED: Veterinarian's: License No. Year 4 le /3 Other Change LI Add CI TNATK7Ers:/ce Control No. 8 \RABIES VACCINATION CERTIFICATE Rabies Tag Number NASPHV Ryan ISO Owner's Name & Addn3ss trim - use bell poInt pen or typo -PRINT Spec:les Dog X Cat — DATZE3 1 yr. Lic.Naco. sigrefgzos (First 3 lathes) UcJVacc . For Licensing Agency Use license No. Year hr Jr 13 f. ve"A, - Other Signature Change la Add u Control No. KEY E VET :IFiVRVFS1 RABIES VACCINATION CERTIFICATE Rabies Tag Number NASPtiV Pam 050 Print - use bail point pen or type iet te'LLYjjzial Aoe. • 3 ox). to 12 moj4 Under 20 lbs. u Z.74ed 12 mo. or older CI 20-60 lba. _ dmed: 2 Over 50 lbs. Ea sc).114esittb;_oZ6, .18 ( 1 yr. Lic./Vacc. (First 3 letters) 3 yr. Lk/0ex. Other For Licensing Agency Use DATE VACCINATED: Winn NO. Year 4_ Veterinarian's . # Ci _ wit‘urrito, Year Other Change ra Acid C:1 VETERINARY SERVICES, L.L.C. Cord No. 24O9OWJ1Y 85 OUCKEIE, AZ 85326 VACCINATION RECORD RABIES VACCINATION CERTIFICATE Tag tee S- Name ADAPTED NASPHV FORM 51 Tag 40. 0 RABIES Print - use bell point pen or type Cert. Serial #. D LYME DISEASE Owners Name & Address ..M.I. T116HONE I , CANINE DISTEMPER PRI LAST FIR 5 -t-- fern 11:1 CANINE PARAINFLUENZA STEET R cs....4 21._ a l; AE I El CANINE ADENOVIRUS 2 Ss 55 f\ A 0 CANINE PARVOVIRUS SEX: AGE: SIZE: ' - EDO INANT BREED: COLORS: 0 CANINE CORONAVIRUS SPECIES: Dog Male El 3 Mo. to 12 Mo. El Under 20 lbs. El Ej CANINE BORDETELLA Cat Female RI 12 Mo. or older S. 20 - 50 lbs. 1-e,ratiOdi LI LEPTOSPIROSIS Other Altered El Over 50 lbs. El NAME- 100' L3 CAN./FEL. GIARDIA (Specify) E FELINE LEUKEMIA 4 -----__n D FELINE PANLEUKOPENIA DATE VACCINATED: PRODUCER: Veterinarian's # 0 FELINE RHINOTRACHEITIS 11 Is 1 Sch License No. O FELINE CALICIVIRUS Month Day Yea (First 3 Letters) 0 FELINE CHLAMYDIA 1 yr Lic Nacc Veterinarian's eptlAttark 0 FELINE RINGWORM VA Cl TION EXF. IF ' 3 yr. . Lic.Nacc. ' ' Signature 018 FEUNE IMMUNODEFICIVICY tc.4 VIRUS ii .4 AdgercKm.E_NTTEMIMR-Tingri o th say ar Vacc. Serial (Lot) No. 24090 vi Min. 85 FORT PODGY FDPC0193C Susan Anderson TheNature ci.). 7601 N 185th Ave Conservancy Waddell, AZ 85355-9815 -ick-Avy=Q-zoo VACCINATION RECORD RABIES VACCINKI/ON CERTIFICATE Tag fee $' Name ADAPTED NASPHV FORM 51 Tag #* E RABIES Owners Name & Address Print - use ball point pen or type Cert. Serial #. E LYME DISEASE P T LAST Fl M.I. PHONE El CANINE DISTEMPER I E CANINE PARAINFLUENZA NO STREET A;ITY ZIP D ) A icss- (Jaye( A S5-35s- CANINE ADENOVIRUS 2 E CANINE PARVOVIRUS SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS: Dog 1s1 Male El 3 Mc. to 12 Mo. LI Under 20 lbs. El O CANINE CORONAVIRUS Cat Female -gl 12 Mo. or older ril) 20 -50 lbs. iiO'Skaarkidagiiii 6 61./IC E CANINE BORDETELLA Other El Altered LI Over 50 lbs. fl NAM E LEPTOSPIROSIS (Specify) E CAN./FEL. GIARDIA El FELINE LEUKEMIA CAE VACCINATED. PRODUCER: Li FELINE PANLEUKOPENIA WI Veterinarian's # NM-473 El FELINE RHINOTRACHEITIS ft • License No. Month Day Year E FELINE CALICIVIRUS (First 3 Letters El FELINE CHLAMYDIA rr----- --- 1 yr. Lic.Nacc. Verennarian'sopt Firtilib E FELINE RINGWORM VACCINATION EXPIR 3 yr. Lic.Nacc. V Signature El FELINE IMIVI8NODEFICIENCY ) SI ei4C01:0 gyratgyE_vrrEitoutRy_ssavt, VIRUS Month Day ear Vacc. Serial (Lot) No. ES 24890 W. HWY, 85 h — I", [NAL. FDPC0193C RABIES VACCINATION CERTIFICATE Rabies Tag Number NASPHV Form 050 Owner's Name & Mdrees Print - use bail molt ben or type PRINT - '•\ :al At IA ikciAll i AA .2 ing.Clillitaill011,5774MME011 LzL] Age: size: Dog Male U 3 mo. to 12 rri3,4 Under 20 lbs. )4 at U tAnks,2 rt.*. or older 20-50 Itys. 111161a1Waraggr Over 50 lbs. U Vex. Serial got) No. 1 yr. LiciVacic. (Fed 3 160818) 3 yr. Lic.Neco. other SitaPS For Licensing Agency Use DATE VACCNATED Vetedruutan's: # License No. Year Signature Other VA NVI SE LL. Change 0 Add U kK[:EVE Control No. 24090 VV. HWY 85 RABIES VACCINATION CERTIFICATE Rabies Tag Number NASPHV Form 050 Ovmer's Nene & Address , 2rInt - uae bell_pelsitpen er hge PRINT • milinizavr 1117111- (Rat 3 Itglers) For Licensing Agency Use Ucerse No, Yeas Other Change U Add ID Control No. 2- RABIES VACCINATION CERTIFICATE Robles Tao Number NASPHV Form #50 Print • use hal Debt oirl or hoe UCKEYE VETERINARY SERVICES, Lit. 24090 W. HWY 35 ' lb RABIES VACCINATION CERTIFICATE Fteblim Tag Number NASPHV Fonn#50 Owner's Name & Minos Print - use ball mint yen or type Vs= Serial (lot) No. Producer: U 1 yr. liciVacc. (Rod 3 leOers) 3;ris yr. LicJVacc. 31f5-C?J43 For Licensing Agency Use DATE.YAOCINATED: License No. Year 4-W /3 MOrdh Day Year Other TOON EXPIRES: Change Li Add a Cr:carol No. te EVETE6iNARY SERVICES, LLC. 2490 IN, HWY 85 ILICKEYE AZ 85328 7 --- VACCINATION RECORD RABIES VACCINATION CERTIFICATE Tag lee $- Name ADAPTED NASPHV FORM 51 Tag *- • RABIES Owner's Name & Address Print - use WIT-point pen or type Cert. Seri& #: -LYME DISEASE PRIN'LAST/ FIRST M.I. TcLEPHONE fl CANINE DISTEMPER Arid€456 o S(25ari ta. e_3 _3331 [j] CANINE PARAINFLUENZA NO. STR CITh'i STATE ZIP El CANINE ADENOVIRUS 2 749/ 4/ 0 CANINE PARVOVIRUS SrECIES: AGE: SIZE: .0 PREDOMINANT BREED: COLORS: • CANINE CORONAVIRUS Dog r Male r 3 Mo. to 12 Mo. Under 20 lbs.. Cat Female 12 Mo. or older TI*4 20 -50 be. . la‘rtehisiie chef-- 0 CANINE BORDETELLA I Other Altered Over 50 lbs. El LEPTOSPIROSI s El CAN./FEL. GIARDIA (Specify) 5/43* ki El FELINE LEUKEMIA DATE VACCINATED: PRODUCER: fl FELINE PANLEUKOPENIA Veterinarian's # 37 1 3 FELINE RHINOTRACHEITIS 3o 1 0 4) e r License No. • FELINE CALICIVIRUS Month Day Year (First 3 Letters) • FELINE CHLANIYDIA 1 yr. LIc.Nacc. Veterinarian's atria El FELINE RINGWORM VACCINATION EXPIRES71 3 yr. Lic.Nacc. gl_ , Signature *At% 0 FELINE IMMUNODEFICIENCY q 30 13 4---52foa A-- VIRUS Month Day Year Vacc. Serial (Lot) No. AddressBUCKEYIBATBIPEREVARY 81 CE13 — — 24090 W HWY. TITTATTIVE . Tra A FDPC0193C Age: toM 3mo.t012mo. 1.3 12 mo. or Wad Car. 1 yr. LicJVacc. 3 yr. Uc./Vacc. For Licensing Agency Use License No. Year RABIES VACCINATION CENTIFICATE hables Tag Number ALASPHV Form 050 Owner's Name & Address Print - use bail point pen or type PRINT - M.I. Speolesiir i Sex: Predomrneiffireed: Dog Male ID 3 mo. to 12 rno.JA Linder 20 lbs. J grorakto 12 rra. or older ta 20-50 lbs. t ri3=111:)/1" Over 50 lbs. Pa0c4f. rx117511 Vacc. Serial (lot) No. LicJVacc. (First 3 lettere) Li 3 yr. lic.Nacc. Other 12.511121 For Licensing Agency Use DATE VACCINATED: Ucense No. Year Veterinarian's: # -X4r.s. License No. Month Day Other ciNATta -*nature - Change 0 Add 1 112.21a N. 14661-44 4 !) Control No. --ST4Ait iSt.1412 rmvi4E-loys ear