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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 0 New \-)Ti.J,, Renewal Permit it_i t; Name: 2 ry1 (05 k.)) IS(r) r Kennel Name: )./01 Drm n Mailing Address: -0,„ I- Lir\ Kennel Location: e /) 3 n4-4.-, L City ()))0 C 6\ , AZ ZIP s'scg3 County Supervisorial District Lf e_ Home Phone: ec, 3— ki.3q 3 Kennel Phone: OA 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 property 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. 21t4/ 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). • - INVe certify that the kennel has been approved by the local zoning authority (if applicab!e) at the poen-iises for which lIwe are making application for a permit. 3 --AA- INVe certify that INVe have dogs and that the kennel meets the definition in statute. I/VVe certify that I/VVe have not been convicted of a violation of A.R.S. §§ 13-2910 (cruelty to animals) og 1.3-2910.01 (dog fighting), or any other state, county or municipal animal welfare law. (Violations of license a,ruk leash laws DO NOT apply.) 5.riroki I/We certify that all dogs over the age of three (3) months that are kept, harbored or maintained on the preniises 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. 6. /We certify that INVe are submitting a valid copy of the rabies vaccination certificate for each dcia with this application. 7.42L 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 11-1008 except if the dog is only being transported to another kennel which has a permit issued under this section. 1\, 8.7 UWe understand that a person who fails to obtain a kennel permit under ARS 11-1009 is subject to a ptnalty of twenty-five dollars in addition to the annual fee. 9. i/1,-/j 1=e understand that a person who knowingly fails to obtain a kennel permit within thirty days after wntten 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 not limited to bré<ers, groomers or boarding establishments? (Please check one) YES j/Z:_) 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 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. 110 4=1 -1/We 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 information I/We have provided is true and accurate under penalty of law. 0 Applicant Signature C-t,> c.‘.i& 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: R13-167051 Receipt Date: 08/27/2013 Person ID: P1205200 Phone: 623 4348338 WILSON KENNEL 28022 N 30TH LN 8/27/2013 3:02:40PM PHOENIX, AZ 85083 Item: Animal ID: Reference No: Price: Each: Amount: KEN PERMIT A1777555 K14-000042 $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: A1777555 DUSTY RAE - BORN 11/10/2003, FEMALE, CHIHUAHUA SH, BLACK AND BROWN DOG License Information: Tag Number: License Expires: Animal# Vacc Date: Vacc Expires: Please retain this receipt with your pet's records KJENSEN EBUSOFF F. — ar ss 3—r /..._ i: 3r ss 3 yr. 1 yr. 0 a Li 3 yr. 1 0 „TS 0 yr. Lic.N. PRODUCER: 12 3 AGE: FIRS PRODUCER: 12 3 AGE: '"•••.N. Lie.Na. Mo. Mo. Nac- Lic.Nacc. Mo. Mo. . C. or to RABIES • or to A RABIES older 12 • 0 older 12 Vacc. (F r Mo. Vacc. /2-7 (Firs Mo. t 3 PRINT ADAPTED PRINT ADAPTED Serial A N1 Li - Serial /5 ,.1)3 r.] AI. - (Lot) Letters) Over 20 Under S Y IT use VACCINATION (Lot) -3 ers) -: Over 20 Un 4.401 use VACCINATION , - 50 ball - 50 ball No. lb 2ii point NASPHV No. '1/7g4 50 lbs point NASPHV b". lbs. es./ pen pen .411116... I'1 A or FORM I or FORM 5 'I • R type r cte. type Address Signatur- r 51 CERTIFICATE ... Address Signatii Veterinarian 51 CERTIFICATE ' Veterinarian's Veterinarian's 4444\ Veterinarian's PREDOMINAN isOMINANT ..,STts MI STA MI # APP. ,' IA' E , L License .• BREED: / ,REED: Ardir Y4 d. Nolz.No. 5 - . N ,-, I;" rielP ...... ZIP ert. Ta g i+Fraiikr IP TEL Cert. Tag Tag 4 ....* ...0,-- COLORS: . fee COLOR? #: fee . - TELEPHONE Serial -,.1_<!--;.,, 1 1; Seria $: --e--ii.":". MALN, #: —L , /At ' /4#1 (42:) , •:P.>g --7 -il7i Month -- Month • DATE (Specify) Other Cat Dog SPECIES: .2 = NO. PRINT Owner's VAC0410001 Month 7 Month DATE (Specify) Other Cat Dog SPECIES: NO. PRINT Owner's -7 VACCINATION 0 0 S (..). VACCINATION 7 0 0 ,›; 25'022 LAST LAST /3 VACCINATED: 14,11,--50/1 Name if VACCINATED: Name Day Day /i 22. & Day .)., ay /3 111/6.5011/ & i EXPIRES, Altered Female Male SEX: STREET, EXPIRES: Altered Female Male SEX: /ii, STREET Year ii.._ Year 4 i Address Year izi„. Year 1) Address . / 3 yr. 1 yr. 0 Rr 121 3 1 0 0 ,3!iitr iY) yr. yr. PRODUCER: 12 3 AGE: FIRST PRODUCER: 12 3 AGE: Lic.Nacc. Mo. Mo. j Lic.Nacc. Mo. Mo. ,Xki., FNiti Lic.Nacc.f or to V/H . RABIES Lic.NaccX or to RABIES CI older 12 V ril older 12 Vacc. . (First Mo. a c /2 (First 4- „7 3 PRINT ADAPTED c . 3 Mo. PRINT ADAPTED Serial , )5k E - Serial /5-. ) ....15e 0 - (Lot) ............., Letters) Over 20 Under SIZE: use VACCINATION Letters) Over 20 SIZE: Clyil9 use VACCINATION - CITTY/ryt. ball (Lot) S - Under ball No. 50 50 20 NASPHV No. 50 50 iet-le NASPHV lbs. lbs lbs. point „L__,27-1 lbs. lbs 20 point pen 7" pen Li E .!>_k or FORM H 0 lbs.,)< or FORM type 5 " type Address Signaur NAME: 51 CERTIFICATE ' Address Signa. NAM 51 CERTIFICATE Veterinarian' Veterinarian's PREDOMINANT Veterinarian Veterinarian's PREDOMINANT MI f o- STA MI # STATE/ 4/ 4 # ,./T.e..._ y , r , License BREED: : / Liceelse t BREED: _ . No. r liO. ZIP Cert. Tag Tag ei-:-,57r ZIP Cert. Tag Tag COLOR #: fee , c - COLORS: g:54-- TELEPHONE #: fee Serial $: 7 - ! Serial $: .....oigt TELEPHONE(62?) #: , #: g(). 5 45_0. / --C-Z5 _ZZ L • 27- ' Ark Animal Hospital 18432 N. Cave Creek Rd. Phoenix, AZ 85032 (602) 788-3445 CERTIFICATE OF RABIES VACCINATION Client Information: Patient Information: Owner: 41.14414F4NE-W I LSON Pet Name: QUIGLEY Address: 28022 N. 30TH LN Species: K9 Phoenix, AZ 85083- Breed: POODLE, TOY Phone: Sex: M Neutered: Yes Color: WHITE Size: ® Under 20 lbs. 0 20 - 50 lbs. 0 Over 50 lbs. DOB: 10128/2001 Vaccination Information: Date Vecchio* 8/21/201 il Producer: VAII-3 Vaccination 8121/2015 Voce Lot #: 18144b E 1 Year Lic.Naccine Premise Permit 1223 k 3 Year Lic.Naccine Veterinarian Signeture: AZ LICENSE #1913 RABIES VACCINATION CERTIFICATE Tag fee $: ADAPTED NASPHV FORM 51 Tag #: Owner's Name & Address PRINT - use ball point pen or type Cert. Serial #: P RI NOTt. 5a.fr, FIR:), it1 MI W..5.1710 * N 0264 T`2 NO. STREET Cptm STATE ZIP 6. .26' 022 N,gZ.- O /V. 4 .Z. SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: C1 4007S: L. Dog X Male 3 Mo. to 12 Mo. E Under 20 lbs. X Par ich 1--- Cat n Female $ 12 Mo. or older X 20 - 50 lbs E Wad PielaN Other E Altered Ei Over 50 lbs. -_-__ NAM (Specify) E ti e., lo q DATE VACCINATED: PRODUCER: Veterinarian's # / 13 f TD License No. ir Month Day Year (First 3 Letters) Veterinanan's i ,-- 1 yr. Lic.Nacc. — Signature . _ 73 VACCINATION EXPIRES: _736 ez6 g / 1 3 yr. Lic.NaccX/.21 Address • 0 0 0( , CC"i5de7/e,, A.2 Month Day Year r Vacc. Serial (Lot) No. b'sc.25:2 VAC0410001 RABIES VACCINATION CERTIFICATE Tag fee $: ADAPTED NASPHV FORM 51 Tag #: Owner's Name & Address PRINT - use ball point pen or type Cell. Serial i't: T/i. LIT s or) F.ZST1 MI TELEPHONE (23) J ) 01 ‘134-F33 PR(IA Th. ZIP 1,Y 02./ 11 30 1-4 1 . Xt. '5 e3 SPECIES: SEX: . , AGE: SIZE: PREDOMINA!vT BREED: COLORS: Dog X Male ":1! 3 Mo. to 12 mo. E Under 20 lbs. A C A 1 13 rowel o (1- Cat C Female 7.: 12 Mo. or older X 20 - 50 lbs . Other C Altered C Over 50 lbs. -_-_. NAME: E IA rte. (Specify) cfrviso 0 DATE VACCINATED: PRODUCER: Veterinarian's # 12 5-0 F 1 3 F y I) License No. Month Day Year (First 3 Letters) ..- ...--- --i• Veterinarian 7.. 1 yr. Lic.Nacc.::. Signatur 40,V12‘e 17M VTINATICN EXPIRES: 6 Lic.Nacc.K I a i 5 3 p 0 g ocicii 3 yr. Address , 1 A .- ,f, Month Day Year 5ceir-s-I14-LE Vacc. Serial (Lot) No. 6°52 VAC0410001 RABIES VACCINATION CERTIFICATE Tag fee $: ADAPTED NASPHV FORM 51 Tag #: Owner's Name & Address PRINT - use ball point pen or type Cert. Serial #: ck PRINT LikST/ FI,T MI TELEPHONE 2 w t o / leo L1314 -) CITY 1. T ZIP6-0 6,3 N9.2102si EET AA 30 L o. —ph ,If SPECIES: SEX: AGE: SIZE: PREDOM1, 'NT BREED: COAI R 4. Dog bir Male 17 3 Mo. to 12 Mo, :21 Under 20 lbs. X Vo I/. ) e 6 ii Veer Cat 0 Female >e 12 Mo. or older ./k i 20 - 50 lbs Other D Altered 0 I Over 50 lbs. _ --1 NAME: . • J (Specify) IT :2-,.../ DAT t VACCINATED: PRODUCER: N U Veterinarian's # 12- 570 I 3 License No. Month Day Year (First 3 Letters) Veterinarian's 1 yr. Lic.Nacc. :I: f. Signature „Ob. VACCINATION EXPI T(Z x f i 0 3 yr. Lic.Nacc. Address 87 ) 12153 OR Month Day Year 4 L j. Vacc. Serial (Lot) No. (Y15-2'3-2 VAC0410001 RABIES VACCINATION CERTIFICATE Tag fee $: ADAPTED NASPHV FORM 51 Tag #: Owner's Name & Address PRINT - use ball point pen or type Cert. Serial #: PRI NT l'871,.. F I P4itT 1 MI ItiEprEir33p ( 2-3) --- w I ,)0ii J 1 01 N51025REETIV 30 , ,,., CITY ph sALE2 zirsvo Lig- A--- SPECIE.S:r SEX: AGE: SIZE: \rPREDOMINANT BREED: COLORS: r Dog X , Male 0 3 Mo. to 12 Mo. L-.: Under 20 lbs. 6) Creqev) Cat C Female X 12 Mo. or older X. 20 - 50 lbs I Other 0 Altered 0 Over 50 lbs. NAME: I) (Specify) DA VACCINATED: PRODUCER: Veterinarian's # /ETV° f 13 Er D License No. Month Day Year (First 3 Letters) Veterinarian's . 1 yr. Lic.Nacc. _ Signature , . .0",4,K 00. 7/1 V C INATIOtilEXPla : Srarfigaltief 3 yr. Lic.Naccie Address f ai b--)62A Virdinglig Month Day Year Vacc. Serial (Lot) No. VAC0410001 RABIES VACCINATION CERTIFICATE Tagfee $: ADAPTED NASPHV FORM 51 Tag #: Owner's Name & Address PRINT - use bail point pen or type Cert. Serial #: PRINT ,1_41 Envy) MI TELEPHONE (16•2 0 wl soy) 1-1314 6133e NO2 . 600 :1101EET N CITY SAt ZIP8)5-06)3 0 Lr) 3 ‘ SPECIES: , SEX: AGE: SIZE: A _i PREDOMINANT BREED: COLORS: Dog ,_< Male Li." 3 Mo. to 12 Mo. 7 Under 20 lbs. rig CirtI'cicilej Cat :... Female g 12 Mo. or older )1( 20 - 50 lbs - .., It Other 7_, Altered ---, L_, Over 50 lbs. 7:: NAME: I I t#14)* (Specify) (3q 04 V / DATE VACCINATED: PRODUCER: Veterinarian's # 1 a &0 1? I 13 F 1•1) License No. Month Day Year (First 3 Letters) Veterinarian's .- 1 yr. Lic.Nacc. :2 Signature / / VAC NATION EXPIRES: 0 • A i 3 yr. Lic.Nacc. Address MIN CY + ) ) 215362 7- 1 Month Day Year $ ii=lig -2- Vacc. Serial (Lot) No. r 5— 2. .5- 2.. VAC0410001 RABIES VACCINATION CERTIFICATE Tagfee $: ADAPTED NASPHV FORM 51 Tag #: Owner's Name & Address PRINT - use ban point pen or type Cert. Serial ft: PR IN T LA MI Ti7EPI-ili ONE C &I 7;41 3 - 6033 MIS 0 ti N16)01E21/ 30 tm. crow_ s-A2... zy cr)63 SPECIES: SEX: AGE: SIZE: _ z FRED BREED: COLORS Dog V Male C,...3 Mo. to 12 Mo. J. Under 20 lbs. X 01 d-4 _ Cat C Female IS 12 Mo. or older X 20 - 50 lbs Other C Altered .__. _ Over 50 lbs. i NAME: i 6rowo (Specify) D oily DAT fs) VACCINATED: . PRODUCER: Veterinarian's # la 570 License No. 1 1 3 FT-D Month Day Year (First 3 Letters) Ns. Veterinarian 1 yr. Lic.Nacc. : IT Signature • vAe NATIONI EXPIREI i liniET21 - ittrf. 4 3 yr. Lic.Nacc Address ,2A Month Day Year 411NIVINtralg Vacc. Serial (Lot) No. 2 : VAC0410001 RABIES VACCINATION CERTIFICATE Tag fee $: ADAPTED NASPHV FORM 51 Tag #: Owner's Name & Address PRINT - use Pall point pen or type Cert. Serial #: P NT t. Fl MI TELEPHONE ( g 23) 1 b al 7 l (71/1 L/3/1 - 8332 6, 5.0 6,3 NO _ S TB EET CITY 40/ , STATE,_ ZIP 28o2 2 N, 30 i — n , T VIA- spECIE;,.. SEX: AGE: SIZE: tr. PREDOMINANT BREED: COLORS: Dog Z*4 Male 3 Mo. to 12 Mo. E Under 20 lbs. e Ct.? I C l/pmpc7,vicoL Cat ' 7_7, Female 12 Mo. or older .7‘ 20 - 50 lbs — Other..7. Altered Over 50 lbs. — NAME: tAki rfe (Specify) Peg C C-5 DAT. VACCINATED: . PRODUCER: Veterinarian's # / 1 5° 3 Fir License No. i i 40 Month Day Year (First 3 Letters) Veterinarian ..1 1 yr. Lic.Nacc. 72 Signature . / A IC,CINATION EXPlRES. 3 yr. Lic.Nacc.yr i 2 1 5-362 h IIMMISIMIF ‘6 / ) Address i .2. Month Day Year dili . q C Vacc. Serial (Lot) No. ifS-,2-5- VAC0410001 RABIES VACCINATION CERTIFICATE Tag fee $: ADAPTED NASPHV FORM 51 Tag #: Owner's Name & Address PRINT - use Pall point pen or type Cert. Serial #: PWAS) . MI T LE).EPHONE 62. 3) F7 3 33-1 .30 1.... 1 vi i NI.1.2 eo2S..07ETAL CITY pheir_ STATA2 ZIP 06, 3 SPECIES: SEX: AGE: SIZE: ,r PREDOMINANT BREED: COAN: Dog X Male E 3 Mo. to 12 Mo. :_ Under 20 lbs. lc C i Pi oic Cat E Female 3e 12 Mo. or older 20 - 50 lbs Other — Altered El Over 50 lbs. .::: NAME. , s 1/) at ctic ,,v (Specify) DATE VACCINATED: PRODUCER: fa 60 Veterinarian's # f-1 12 License No. 1 1 ) Mo 1i) th Day Year (First 3 Letters) Veterinaria• _ 1 yr. Lic.Nacc._ Signet VAgNAT10111 EXRI1t6 3 yr. Lic.Nacc. Address JIM " A OMF1-- A itil tr I 2./ 5 3 6:21 Pr e I Month Day Year .S t Vacc. Serial (Lot) No. es-25- VAC0410001 RABIES VACCINATION CERTIFICATE Tag fees: ADAPTED NASPHV FORM 51 Tag #: Owner's Name & Address PRINT - use ball point pen or type Cert. Serial #: PR wrz.„...50/, FIRS) MI TELEPHONE(e2) 3 i;0 l ,..._ NC .. s, 0 2 r R2 li / ,. 3 0 4 CITY r 4.......x STATE E 4 _.4 ZIP (5-eg3 /1 L.— SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS: Dog ''''' Male :: 3 Mo. to 12 Mo. 0 Under 20 lbs. 'r:I'' Cat E Female 5 12 Mo. or older >-4- 20 - 50 lbs 7 Other El Altered Over 50 lbs. ' NAME: me (Specify) ."0. DATE VACCINATED: PRODUCER: hi : Veterinarian's # /- Z70 / 7 ‘3 Lcenso. e N Month Year /1 (First 3 Letters) Veterinarian's ...„ ar. 1 yr. Lic.Nacc. L.., Signatu e ire VACCINATION EXPIRES: /7 / 3 yr. Lic.Nacc. . .-, Address P'. 410M79 _ -- -47;!1.- • ... 3 5g A cr ...-, , Month ba/y "Z/O .....- /Y--" ar Vacc. Serial (Lot) No. -,..27"-.." 1 ..c....,......a.. VAC0410001 RABIES VACCINATION CERTIFICATE Tag fee $: ADAPTED NASPHV FORM 51 Tag #: PRINT - use ball point pen or type Cert. Serial #: . Owner's Name & Address OZ PRINT LAST FIRST MI TELEPHONE I . \ILCI NO. STREET S-T , TE ZIP ---0 25 oz .Z. A1 - _,'_-,f_. /-1 z_ g3 SPECIES: SEX: AGE: SIZE: PREDOMINANT B Ep. COLORS: Dog )<- Male El 3 Mo. to 12 Mo. D. Under 20 lbs. ›; , / Cat E Female 12 Mo. or older X r.' 20 -50 lbs ---, -1Z.' Other D Altered Eli over 50 ibe. li NAME: (Specify) 5-674 4 (e. DATE VACCINATED: PRODUCER: Veterinarian's # /Zs-6 ic L ense No. 7 13 i I Month ay Year (First 3 Letters) Veterinarian's ...-- 1 yr. Lic.Nacc. _ _ Signature VACCINATION -7 i :3 EXPI /14. RES: 3 yr. Lic.Nacc. X Address Z-..___./fee;._____fYr _2_..7,,_____ Month Day Year / 2/ 511. S—C i Vacc. Serial (Lot) No. ' l I 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 7 7 , FIRST, ,1_, MI TELEPHONE(f4 11,7 CITY S-i17 , ZIP y i)2 ,T r ET A/ -'0 ,, ,' /f /-2A,A ..-- SPECIES: SEX: I AGE: SIZE: PREDOMINANT REED: COLORS: Dog Male 3 Mo. to 12 Mo. E Under 20 lbs. 5C: Cat E Female1,-1 12 Mo. or older W., . 20 - 50 lbs — Other IT Altered LT Over 50 lbs. .1.- NAME (Specify) DATE VACCINATED: PRODUCER: Veterinarian's # 7 /5 1/ License No. Month Day Year (First 3 Letters) — 1 yr. Lic.Nacc._ Signature n / VACCINATION )5 EXPIRES: py, 7 3 yr. Lic.Nacc. ...., Address r -4 . 1-Z---,7C-, S-7-'e(11/- 4- Month Day Year .25.--, 7g/ .5z- - — ---, Vacc. Serial (Lot) No. 7— VAC0410001 RABIES VACCINATION CERTIFICATE Tag fee $: ADAPTED NASPHV FORM 51 Tag #: Owner's Name & Address PRINT - use beIl point pen or type Cert. Serial #: PRINT LAST FIRST MI TELEPHONE 632_3) i/t/r-Lpsie-Ai .si /Ai' q,-._;7 - R-33 g NO. STREET , CITY ri STAT ZIP , z .2- A .26) :4.1 .4,--}c, t?.Z t(/).° SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS: Dog >IF Male C 3 Mo. to 12 Mo. E Under 20 lbs. -:-..- _ C4' 0 Cat CI Female 12 Mo. or older >4"- 20 - 50 lbs Other [2, Altered r2 Over 50 lbs. ,- NAME: • , (Specify) DATE VACCINATED: PRODUCER: Veterinarian's # 7_. 5—C -7 I / / , Pr)) LicenseNo. / 7 Month Day Year (First 3 Letters) Veterinarian's7 , 1 yr. Lic.Nacc. _7: Sigrature;<.! ' VACCINATION 1 g EXPIRES: i q- 3 yr. Lic.Nacc,>r . Address ,/,,,_ : 7 Month Day Year Vacc. Serial (Lot) No. VAC0410001 RABIES VACCINATION CERTIFICATE Tag fee $- ADAPTED NASPHV FORM 51 Tag #. Print - use ball point pen or type Cert. Serial It• Owner's Name & Address 2 - PRINT LAS1 FIRST M.I. TELEPHONE W i /SOO ':.) ivy) '13 Li - 3, 6) NO. STREET fil ST ZIP 573 aeoaa N, 30 L 1,7 . ( Y SPECIES: SEX: ,._.e.' AGE: SIZE: k PREDOMINANT BREED: COLORS: Dog 1g Male A 3 Mo. to 12 Mo. Under 20 lbs. i Cat fl Female 12 Mo. or older x , 20 - 50 lbs. C' 1-11- To Other E Altered Over 50 lbs. E NAME: L._ f (Specify) cil DATE ViCCINAT,ED: PRODUCER: I 2570 r.) 1 .28 /0 -1 i D 1 Veterinarian's # License No. i Month Day Year (First 3 Letters) %. 1 yr. Lic.Nacc. Veteri . VACCINATION EXPIRES: 3y Lic.Nacc. Sign1.7 4 7 Address . °- _ t- 0 EN • • , 5- ., Month bay Year Vacc. Serial (Lot) No. 3 cori-le4 FDPC0193C RABIES VACCINATION CERTIFICATE Tag fee 5' ADAPTED NASPHV FORM 51 Tag St. Print - use bill point pen or type Owner's Name & Address Cert. Serial it . PRINT /LAT 4RST M.I. TELEPHONE 62 14/ i SI) ii ,Jirvi r) NO. STREET ZIP e a) Iv, 30 1-, Ptix 5-067 3 0 22 SPECI. SEX: , b.." AGE: SIZE: ...A PREDOMINANT BREED. COLORS: Dog 1E, Male ak! 3 Mo. to 12 Mo. Under 20 lbs. liSi Ur Y1Cr k i c 0 1--ritheA1 Cat E Female 12 Mo. or older 20 - 50 lbs. Other Altered Over 50 lbs. D NAME: (Specify) ill DATE VACCINATED: PRODUCER: I 2 5-0 Veterinarian's # / Ai; 12 1' i *D License No. Month Day Year . (First 3 Letters • 1 yr. Lic.Nacc. Veter' VACCINATION EXPIRES: Syr. Lic.Nacc. signat 7 _., --;.4 //._, v i)LTL:?: 5 7/} Addres EirP VeC AM • Month Day Year Vacc. Serial (Lot) No. C (,- , inf - J.2 25- FDPC0193C RABIES VACCINATION CERTIFICATE Tag fee V ADAPTED NASPHV FORM 51 Tag #. Print - use ball point pen or type Cert. Serial #. Owner's Name & Address TELEPHONE c23— PRINT X LAS1 FT M.I. /11 Sov) ,..1 1 ill NO _, STREET /1/ 97 to i Cr STAITE ZLI IP3i/.520?d)3 131 7-- 2_ i---0 ././--2_ a hi 0 . SIZE: PREDOMINANT BREED: COLORS: SPEC:k. SEX: AGE: Dog 1 Male 3 Mo. to 12 Mo. Under 20 lbs. C I-1-1: 84/1/A4fT Cat Female .N. 12 Mo. or older 20 - 50 lbs. Other fl Altered Over 50 lbs. E NAME: t (Specify) 4 —01/1 DATE V / CCINATOD: PRODUCER: I .----- 1 Veterinarian's # I ZS-0 F IT A License No, 7 2-(S) / /.2 Month Day Year (First 3 Letters) 1 yr. Lic.Nacc. Veterinaria ' VACCINATION EXPIRES: 3 yr. Lic.Nacc. Signatur- _.., / /Ill 5 35 Address OM Month 77/7? Day Year Vacc. Serial (Lot) No. S . • 2. Cm FDPC0193C RABIES VACCINATION CERTIFICATE Tag fee ADAPTED NASPHV FORM 51 Tag #. Print - use ball point pen or type Cert. Serial #. .,3t)..... Owner's Name & Address TELEPHONE P INT LAS1 . ST M.I. , sok, V3 V—e. i , _ S-, 14..E2 ZIP An - NO crzr Ai, 3 0 65 v e3 1-q. Pkt— SPEC SEX: ....„. AGE: SIZE: t_..4 PREDOMINANT BREED: COLORS: i Dog 9Pci Male n 3 Mo. to 12 Mo. Under 20 lbs. aLi rTkr Cat Female 12 Mo. or older xi- 20 - 50 lbs. CO/ a 1-- E Other E Altered Over 50 lbs. D NAME: (Specify) Sirterc ‘ ,e' DATE yACCINA, TED. PRODUCER: 1 2 5-70, Veterinarian's # 7/2e 1/2 Frp,! License No. Month Day Year (First 3 Letters) 1 yr. Lic.Nacc. fl Veterinarian's inkimior ,/ VACCINATION EXPIRES: 3 yr. Lic.Nacc. 57/i Signature / / , "y .7,' , ,tc?: , /,:„, • f I V ,1 - ..., Addreos Month Day Year Vacc. Serial (Lot) No. ME 4 25— SCC-H5 FDPC0193C RABIES VACCINATION CERTIFICATE Tag fee S- ADAPTED NASPHV FORM 51 Tag If. Owner's Name & Address Print -use bail point pen or type Cert. Serial ft:__ PRINT LAtT WT M.I. TELEPHONE W - J i 671 e 1807,1Eriv / 5 0 ti . 30 , ,s4__,. ZIP rhr;r , 6).5-0623 /41. SPECIES: SEX: AGE: SIZE: K-PRE DOMINANT BREED: COLORS: Dog Male 3 Mo. to 12 Mo. Under 20 lbs. Cat Female 8i12 Mo. or older 20 - 50 lbs. Cffi 1,14/71k€C/ Other E Altered Over 50 lbs. fl NAME: (Specify) SCIS S y DATE VOCIWED PRODUCER: 712e11.2 F Veterinarian's # i 2 5-0 License No Month Day Year (First 3 Letters 1 yr. Lic.Nacc. Veteri .7 VACCINATION EXPIRES: 3 _ yr. L' 1 c.Nacc. / A S. n 1 A Ar '-/ - - V .. Cl< 7 V 121 53 57/t itab • 0 Month Day Year Address . Vacc. Serial (Lot) No. .c( 0 ..- FDPC0193C RABIES VACCINATION CERTIFICATE Tag fee $• ADAPTED NASPHV FORM 51 Tag ft. Owner's Name & Address Print - use ball point pen or type Cert. Serial tf - PRINT LA T 190 M.I. TELEPHONE 23 - jR/T/(11 1-139 3 e STREET ST/7E2 NJ() /4, if 50 6)3 ZIP SPECIES. EX' AGE: SIZE: PREDOMINANT BREED: COLORS: Dog Male 11 3 Mo. to 12 Mo. Under 20 lbs. Cat bJ Female S. , 12 Mo. or older 20 - 50 lbs. (-141- 8/:/i/vt7'i Other fl Altered Over 50 lbs. Li NAME: (Specify) S LI 3 it DATE VACCeINNTEDv: PRODUCER: Veterinarian's # F-Tib License No. Month Day Year (First 3 Letters 1 yr. Lic.Nacc Veterinarian:5 VACCINATION EXPIRES:i 3 yr. Lic.Nacc. Signature 12153 52/1 Month Day Year Address Vacc. Serial (Lot) No. S(.13 FDPC0193C RABIES VACCINATION CERTIFICATE Tag fee 5' ADAPTED NASPHV FORM 51 Tag #. Owner's Name & Address Print - use ball point pen or type Cert. Serial #: PRiNT LAS1 ...4..R,ST M.I. TELEPHONE •-- W) LS 0 0 J i 61 93/.' S). • NO :1-FIEET N 30 /47, Cotikr Sr. ZIP 18D)), SPET SEX: islAGE: SIZE: PREDOMINANT BREED: COLORS: Dog Male 3 Mo. to 12 Mo. Under 20 lbs. Cat Female JJ 12 Mo. or older / gi 20 - 50 lbs. C iiE 6,011,14i-I Other Altered Over 50 lbs. NAME: (Specify) QS CC? r DATE VACCINAED: I PRODUCER: Veterinarian's # / 2570 '7/28112 FrD License No. Month Day Year (First 3 Letters 1 yr. Lic.Nacc. Vete rina i VACCINATION EXPIRES: .3 yr. Lic.Nacc. R Signtru , 4 i ,-., ?2i3 774- Address OK- o6,6 Mo‘ Day ' Year Vacc. Serial (Lot) No. S CI .2 FDPC0193C RABIES VACCINATION CERTIFICATE Tag fee $' ADAPTED NASPHV FORM 51 Tag #. Owner's Name & Address Print - use ball point pen or type Cert. Serial 4*. . PRINT LA FJP5ST M.I. TELEPHONE 6.2 - tdos-v-r Wf sr S ov2 ,. ) i vv-t Li 3 Li -e3 3 .9 A I ,r),, , SAT5... ZIP /v , 'ft) Lfry, Rkr e 5-o 6'3 SPECIr SEX: AGE: SIZE: tj.5„, PREDOMINANT BREED: COLORS: Dog Male 3 Mo. to 12 Mo. Under 20 lbs. Ci 114 5004/e Cat fl Female g- 12 Mo. or older Xi- 20 - 50 lbs. Other fl Altered Over 50 lbs. NAME: (Specify) C C/C`O DATE VACCIN , TED: PRODUCER: fa 5/0 r2i2a) /0 F- lit Veterinarian's # License No. Month Day Year (First 3 Letters .—..." ...,...".*-- 1 yr. Lic.Nacc. Veterina VACCINATION EXPIRES: 3 yr. Lic.Nacc. In: Signat ' / )C/ i °. r/ 7 :1 I 53 -7/?A 0 v Kilonth Day Year Vacc. Serial (Lot) No. Addrefth ., S7f61 1 2- 5-12.5D ( t/ FDPC0193C RABIES VACCINATION CERTIFICATE Tag fee $. ADAPTED NASPHV FORM 51 Tag #: Print - use ball point pen or type Cert. Serial Owners Name & Address P NT 'Air T M.I. TELEPHONE , ievi J i Vv) 4-1.3 1-/ —e3 3 b-) NU 63E:EI N 30 40, si-rir ZIP N 506)3 rki--- SPECK SEX: AGE: SIZE- PREDOMINANT BREED: COLORS: Dog Male 3 Mo. to 12 Mo. • Under 20 lbs werifili-vv) Cat Female 54- 12 Mo. or older 20 - 50 tbs. C.1-f-':1 Other fl Altered Over 50 lbs LI NAME: (SPec1fY) Vk bori DATE Vi,CCINATD. PRODUCER: 1 Veterinarian's # /28 /12 PrD License No. r) Month Day Year (First 3 Letters 1 yr. Lic.Nacc. Veterinanan ,<,c v,„.. VACCINATION EXPIRES.— .. 3 yr. Lic.Nacc. Signature/Y.'. ' - 573 574-- 7 / `r- 1 '' 'Y i 2 ) scd Address Month Day Year Vacc. Serial (Lot) No. - .2 1 2 FDPC0193C RABIES VACCINATION CERTIFICATE Tag fee $:___ ADAPTED NASPHV FORM 51 Tag # _ print . use beg point pen or type Cert. Serial « Owners Name & Address PFrAi T LAtSt r El4T M.I. TELEPHONEs4.2 r i ,0, Li 3 Li- 3 NO. . STRE5.,T silt.T . ZIP 6)5-9,3 6 ,n 8 0 -1- ) i ii i 30 L o 14 4 4- SPECI,- SEX: AGE PREDOMINANT BREED: COLORS: Dog Lx Male fl 3 Mo. to 12 Mo. Under 20 lbs. 01--T Red Cat Female Er. 12 Mo. or older fH 20 - 50 lbs. LI Other Altered 1 Over 50 lbs. NAMt.-]. (Specify) C-ii/ir VI DATE yACCIN 4 TED: PRODUCER: 5---) Veterinarian's # 1 7 Y2/..2Y//.2 F-T-L License No. Month Day Year (First 3 Letters) 1 yr. Lic.Nacc. LI Veterinakr VACCINATION EXPIRES .-- 3 yr. Lic.Nacc. Signatu e _,./". .;?. .. 7 i .:/:77 I !), 1 2 1 53 57 0 to kleig. • Address ' iir an sa M6nth Day Year Vacc. Serial (Lot) No. 3(- 1 "6 0 4 _ FDPC0193C RABIES VACCINATION CERTIFICATE Tag fee S' ADAPTED NASPHV FORM 51 Tag #. Owners Name & Address Print -use ball point pen or type Cert. Serial 1* ._ PRINT Ln s FQ.V.T , Md. TELEPHONE Ep. i 3 — ,J 1 *4/1 '1 3 11- 83 3 P Nl. 60ST2REEZI4 4 0 . Flirt_ sp,....., ZIP 6, 5.1„8 3 At. 13o /7- SPECIES: SEX: AGE: SIZE: V PREDOMINANT BREED: COLORS: Dog K. Male 3 Mo. to 12 Mo. Under 20 lbs. fr-li C-14---Z 7—Cr ti Cat Female IS112 Mo. or older 15-<?"- 20 - 50 lbs. Other E Altered 0 • Over 50 lbs. NAME: (Specify) I 6 ci a DATE Vi\.CCINATiED: PRODUCER: 1(2 5—'0 # 7 428 ii 2 veterinarian, License No. Month Day Year (First 3 Letters 1 yr. Lic.Nacc. Veterinarian's VACCINATION EXPIRES: 3 yr. Lic.Nacc. JE ignature 7 .4 Ls 121 5-35—'?"1-- s 0.7Te • Address ) , Month Day Year Vacc. Serial (Lot) No. c--,,, e • 3 . / ' FDPC0193C RABIES VACCINATION CERTIFICATE Tag fee 5: ADAPTED NASPHV FORM 51 Tag tr . Owners Name & Address Print -use ball point pen or type Cert. Serial 4t P A E. ST, M.I. TELEPHONE 6, 2 37, 17,500 1 m i13 11 of -33e IW 71_1 Nu .655: .4./ 30 AA__ ZIP 1.,,,, SPECIES: _ SEX: AGE: SIZE: ,PREDOMINANT BREED: COLORS: . Dog Male 3 Mo. to 12 Mo. Under 20 lbs. Cat H Female K 12 Mo. or older v. 20 - 50 lbs. Ill C 1+-4-- W frj Other Altered • Over 50 lbs. NAME: (Specify) 6, DATE V,ACC,I NATE?: PRODUCER: 1c2570 1-- Veterinarian's a License No. Month Day Year (First 3 Letters 1 yr. Lic.Nacc. Veterinarian's VACCINATION EXPIRE5: ,.- 3 yr. Lic.Nacc. f2 Signature 1 . ..- / :2-€'; I 1 2) 5 3 6-7A Address ' Month Day Year Vacc. Serial (Lot) No. 0 . i e 2 t' 25 2 FDPC0193C RABIES VACCINATION CERTIFICATE Tag fee $: ADAPTED NASPHV FORM 51 Tag #: Owner's Name &Addresi PRINT - use bell point pen or type Cert. Serial #: PRINT .AS FIRT MI TELEPHON ‘2 3 4//1>on j/ NO. STREET fily STATE ZIP 2 SCO 22' /i/ ?C /-14 W 71 SPECIES: SEX: AGE: SIZE: PREDOMINANT ktREED: COLORS: ive_ Dog ., :N Male E 3 Mo. to 12 Mo. E Under 20 lbs. ,< k_ _ -1/ t Cat E Female .3:g 12 Mo. or older , . . N 20 - 50 lbs 0 (./e - Other E Altered 0 Over 50 lbs. .:: NAM: 4 / (Specify) r.p4b7- DATE VACCINATED: PRODUCER: Veterinarian's # 7 /3 1/ F7 License No. Month Day Year (First 3 Letters) Veterinarian' ---. 1 yr. Lic.Nacc. __ r---, Signatu VACCINATION EXPIRES: 14.... I ...... I - / 7 Address • Ar,:ae._ /3 /.../.5-..5..,g74 ....,.... Month Day Year Vacc. Serial (Lot) No. VAC0410001 RABIES VACCINATION CERTIFICATE Tag fee $: ADAPTED NASPHV FORM 51 Tag #: Owner's Name & Address PRINT- use bell point pen or type Cart. Soria! ft: PRINT LAST FIRST MI TELEPHONE IV/ 430AI •iin ...z, NO. g. (.3„.2z STREET // ,, ....„ 4----fre3 if...‹.4.,,,c. .., ‘__ CIte .4,-,,, STATE ZIP SPECIES: SEX: I AGE: SIZE: PREDOMINANT BREED: COLORS: Dog "ii- Male E 3 Mo. to 12 Mo. 0 Under 20 lbs. ;Vc Cat C Female ..I% 12 Mo. or older 5i. 20 - 50 lbs -`: Other E Altered E Over 50 lbs. E NAME: (Specify) Pi e7/7 DATE VACCINATED: PRODUCER: Veterinarian's # /. 7 /3 // F#7-7) License No. Month Day Year (First 3 Letters) Veterinarian's 31 yr. LIc.Nacc.::: Signatur VACCINATION / 3,- EXPIR i. 9.... : 7 yr. Lic.Nacc.X / , , , Address ,/, i 4-'-/66 <7 5 ,,I__1' 6 41 „,51 . . e . . ,..0.47 — ,--3---zs- Month Day ea,; -"" s- 4 Vacc. Serial (Lot) No. VAC0410001