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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 )6, Renewal Permit # K I LI - M3 E L. Name:MO.01,r Pow\ ho Kennel Name: )V011 .se kits Mailing Address: bg- a 4 IA) YNatev\Lef Kennel Location: bga 1/0. (a r P L-Pe city et/ - 1 ci , Z ZIP F5-3 sa County Supervisorial District Li Home Phone: 1/402 - 9 737 g Kennel Phone: - 1/0 - 9 78 .9 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. AP INVe assume complete responsibility for the kennel at the premises for which Uwe 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. /a_ 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. frrPf) I/VVe certify that I/VVe have /r dogs and that the kennel meets the definition in statute. 4. 444) INVe 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 leash laws DO NOT apply.) 5. _ ))-04= I/VVe 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. 6. I Mk certify that INVe are submitting a valid copy of the rabies vaccination certificate for each dog with this application. 7, VA.LI/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. 8. "N4J---1iWe 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. 1NVe 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 breede'rs, 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. 11. P147 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 I/VVe have provided is true and accurate under penalty of law. (-) Applicant Signature Date: S/ 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.00v Receipt Number: R13-152960 Receipt Date: 0810212013 Person ID: P1224832 Phone: 623 4129739 SHANTE AFGHANS KENNELS 6824 W KAREN LEE LN 8/2/2013 10:43:05AM PEORIA, AZ 85382 Item: Animal ID: Reference No: Price: Each: Amount: KEN PERMIT A7777777 K14-000023 $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 RABIES VACCINATION CERTIFICATE Tagfee $: ADAPTED NASPHV FORM 51 Tag #: Owner's Name & Address PRINT - use ball point pen or type Cert. Serial #: PRINT LAST FIRST yl TELEPHONE 0 7'0 11 e c C I n.4 - ....'._ 6'7) .? . ft" Z2....-?' - I)// ,2 —973. NO. . STREET CITY STATE ZIP 24 ,c.'- .,.- A •C -c 4!,-., a cl- (3-2- SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS: Dog .if-- Male 0 3 Mo. to 12 Mo. 7 Under 20 lbs. 0 Cat 0 Female -f- 12 Mo. or older '/'1 20 - 50 lbs $I /94 14.'1 4 , Other 0 Altered 0 Over 50 lbs. 0 NAME: -Ds----rrt-fr i/ e) (Specify) • el/ DATE VACCINATED: PRODUCER: 1-3 t_ Veterinarian's # 4%. -2 icens,;• I • ) Lt Month Day Year (First 3 Letters) Veterinari • - 1 yr. Lic.Nacc. 0 Si VACCINATION EXPIRES: q / 5 3 yr. Lic.Nacc.K dd 773q Z- 5-7_, onth Day Year Vacc. Serial (Lot) No. VAC0410001 RABIES VACCINATION CERTIFICATE Tagfee $: ADAPTED NASPHV FORM 51 Tag #: Owner's Name & Address PRINT - use ball point pen or type Cert. Serial #: .,..T P.I LAST/ . ) FIRST MI TELEPHONE NO. STREET CITY STATE ZIP /.1,1,1-) 4/ (./ 1 k c, r , ,--, 4 e Le - e4ler-, et- 47-- ;415.57cr.L. SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS: , Dog --- Male 0 3 Mo. to 12 Mo. 0 Under 20 lbs. 0 4 / Cat 0 Female i---,---12 Mo. or older — 20 - 50 lbs tr 1/1,42-k ells 14 Other 0 Altered 0 Over 50 lbs. NAME: (Specify) yo-y-r•H /1 e V ehP'Cl'''/I --‘ g" DATE VACCINATED: PRODUCER: Veterinarian's # V C Zi Ia r License No. 6 Month Day Year --'• 7 (First 3 Letters) Veterinari n's 1 yr. Lic.Nacc.:: Signature rile' VACCINATION EXPIRES: iify -47/4 ii ,011/ ____s• (.3., 1 5 3 yr. Lic.Nacc.X Addr - - Month Day Year 1 77 7 (-4 -2-- - k. E'L`11. C , Vacc. Serial (Lot) No. VAC0410001 CERTIFICATE OF VACCINATION Date of Vaccination: 03-02-11 Certificate No. 0 Next Vaccination on: 03-01-14 Previous Vaccination: VETERINARY CLINIC OWNER OF ANIMAL Sunburst Animal Hospital Marilyn Domhoff 5032 W. Thunderbird Road 6824 W. Karen Lee Ln. Glendale, AZ 85306 Peoria, AZ 85382 602-938-1860 (623) 412-9739 This is to certify... THAT I HAVE VACCINATED THE ANIMAL DESCRIBED BELOW AGAINST RABIES. Patient information... PATIENT: Fancy TAG NO: SPECIES: Canine BREED: Afghan Hound SEX: Female AGE: 4 years WEIGHT: 0.00 lbs COLOR: BLU MICROCHIP: MFG BY: PFI, SERIAL: S056338D, EXPIRES: 07/20/11, ADMIN: SQ Signed: Jessica Reed, DVM License: 4051 Other Vaccinations... Vaccinated By Vaccination Next due 03-02-11 JAR Rabies Vaccination & Exam (none) 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 #: - RABIES 1 .= LYME DISEASE PRINT LAST 1 - y 1 FIRST MI TELEPHONE )0/Y1 11 i, (7-1-s* i12a ,^ / l' 4 1 CANINE DISTEMPER /) NO. STREET STAT5, ZIP CANINE PARAINFLUENZA ,...,_,i /V E CANINE ADENOVIRUS 2 SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS 1= CANINE PARVOVIRUS Dog 7, Male 3 Mo. to 12 Mo. E Under 20 lbs. es-- k CANINE CORONAVIRUS Cat L.-- Female 12 Mo. or older X.. 20 - 50 lbs ' --- CANINE BORDETELLA Other 0 Altered fl t, Over 50 lbs. El NAME: - LEPTOSPIROSIS (Specify) 11 FELINE LEUKEMIA VIRUS DATE yACCINATED: PRODUCER: 3 6 V I - FELINE PANLEUKOPENIA Veterinarian's # n License No. E FELINE RHINOTRACHEITIS 31 174 1( (--' C.----- Month Day Year (First 3 Letters) 1- FELINE CALICIVIRUS Veterinarian' — LT FELINE CHLAMYDIA 1 yr. Lic.Nacc. __I Signature / VACCINATION EXPIRES: , E FELINE IMMUNODEFICIENCY 51 2-4 /(,"-- 3 yr. Lic.Nacc. K. Address VIRUS Month Day Year - .Z. ( 1 72( Ft ( ' e f- f t' Y ) acc. Serial (Lot) No. Boehringer 'AC0410001 Ingelheim RABIES VACCINATION CERTIFICATE Tag fee $: ADAPTED NASPHV FORM 51 Tag #: Owner's Name & Address PRINT - use ball point pen or type Cert. Serial #: PRINT-0ST I 06 FIRST MI TELEPHONE 01 1-' /4 151 .1 /r ii NO. STREET if CITY i STATE ZIP 5/ i' L 1 i‹, !fr., 0 4 SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS: . Dog Ie.-- Male E3 Mo. to 12 Mo. E Under 20 lbs. E Cat 0 Female 12 Mo. or older Er-20 -50 lbs 0 -1 A 1 1 /:9 Other 0 Altered 0 Over 50 lbs. L-1-' "NAME: (Specify) ,-- 6. \- DATE VACCINATED: PRODUCER: Veterinarian's ..3 C L' ense N. ......_ Month Day Year ( irat 3 Letters) Veterin 1 yr. Lic.Nacc.0 -1. -ture VACCINATION EXPIRES: 4;.. .... 3 ,.....1 3 yr. Lic.Nacc.X • •dr. - Month Day Year 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 #: PRINLLAST FIRST MI A TELEPHONE hi; (^)-P A - ,-/) /7. -,2-._-3- -4//..2 —92 . DelYt- STREV CITY i i STATE ZIP I-- e -L. Act /I- /9, SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COL : Dog Male 0 3 Mo. to 12 Mo. 0 Under 20 lbs. 0 .1 A rtia-A4 Cat 0 Female 0 12 Mo. or older L'Y' 20 -50 lbs 4-+1 Other 0 Altered 4- Over 50 lbs. L.1 NAME: (Specify) DATE VACCINATED: PRODUCER: Veterinarian's # ; , 8' — 3 - ( c2 f c ( ticense o. Month Day Year (First 3 Letters) Veterinarian's 1 yr. Lic.Nacc. E Signature ./.‘....-' VACCINATION EXPIRES . k 3 yr. Lic.Nacc. Add s . .,... / 5 / 02 ,S C _4) CO 0 _ Al ;-,—.% r .1 t 0 .3 ? 5-- Month Day Year ' . Vacc. Serial (Lot) No. VAC0410001 RABIES VACCINATION CERTIFICATE Tag fee $: ADAPTED NASPHV FORM 51 Tag #: Owner's Name & Address PR/NT - use ball point pen or tYPe Cert. Serial #: PANT LAS T, ,-y,1 FIRST . MI TELEPHONE ‘:2-5 --1'6" NO STREET . /) STATE ZIP 4,1 / &I *dr"' I / -- Cr 11 1 7 17PtA-- 2— SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: C LORS: Dog Yr- Male S 3 Mo. to 12 Mo. 0 Under 20 lbs. E Cat 0 Female 0 12 Mo. or older — 20 - 50 lbs Other 0 Altered 0 Over 50 lbs. S• NAME: (Specify) s 5 I\ ,eci DATE VACCINATED: PRODUCER: Veterinarian's # 0,...6c) ! . Lic se No. 6- 3--- / 2 )' - 1, / Month Day Year (First 3 Letters) Veterinarian's 1 yr. Lic.Nacc. IT= Signature VACCINATION EXPIRES: / ‘'' 3 yr. Lic Nacc. )i . . Address I t9 cres—G7 4, c 0 ..7:? 7-5 Month Day Year 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 #: PRINT LAST I FIRST MI TELEPHONE - 1.261 rn h cce ill 9-AL, it jil NO. STREET CITY STAT .% ZIP . ti.' l (.4-rei) /- ze Li7 SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS: iiii. 4 ..) 1 Dog Male 3 Mo. to 12 Mo. 0 Under 20 lbs. 0 ‘--)/ if Cat 0 Female 0 12 Mo. or older 't-20 -50 lbs .___1 • ‘.41 . Other 0 Altered 0 Over 50 lbs. j< NAME: it (Specify) 30 nds /.1 -N DATE VACCINATED: PRODUCER: /--) . 4 Veterinarian's # . / . -7 45"-- 6 — 3 — 1 gi i Li ense No Month Day Year (First 3 Letters) Veterinaria 1 yr. Lic.Nacc. _ Signet VACCINATION EXPIRES: -"-- 3 yr. Lic.NacOy i'-- — 3 — ' '1 Month Day Year 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 #: PlitN.T LAST b i ii FIRST ) MI TELEPHONE --1-le r-rt he tr- p1,4,2; te . t 62_3 - './a -7. ill • NC). STREET STATE ZIP e, 5':-..? A,/ /r', H4- (2,1 2,, c, '' 17 77)4,i-y,... A 2- SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: CO)r.ORS: Dog our Male e---1 Mo. to 12 Mo. 0 Under 20 lbs. 0 ) ( 1 Cat 0 Female 0 12 Mo. or older .7_1-20- -50 lbs 2-.-- ' -, Other 0 Altered 0 Over 50 lbs. li: NAME: (Specify) - /A 4, , ---, , - DATE VACCINATED: PRODUCER: -.":" Veterinarian's # .- — 3 — / ?-- icense No. Month Day Year ii) f s i ,. (First 3 Letters) Veterinarian 1 yr. Lic.Nacc. 0 ........„...../........---.7.. VACCINATION is- _ .3 __ EXPIRES: Signatur ., 3 yr. Lic.Nacc.X 1 p g e - ,., ,,... , _ / (-- ) C. `) Address Month Day Year \,' e f c 0 3 --7 3 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 #: PRINT LAST FIRST , ,, A MI TELEPHONE M Atfi b,,,, ./.7- NO. _ STREET CITY . ---, STATE ZIP L(BA-2i L' \ Ul. ( -'ll \,--k` t.I'l.- . CC 0 . . - li 1 0 ' 'i 't Ca_ '=A2.__ S 53 5'•=71-- SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS: Dog y....... Male 3 Mo. to 12 Mo. E Under 20 lbs. P 4:...g.,;,- Aicte, Cat 0 Female 0 12 Mo. or older A-20 - 50 lbs 0 / Other E Altered E Over 50 lbs. (Specify) /1171f "SA • DAT CCINATED: PRODUCER: -SG S"--- Veterinarian' # /-1 2_ P License o. Month Day Year (First 3 Letters) Veterinari n's ..- 1 yr. Lic.Nacc. 0 Signatur.e' ., VACCINATION EXPIRES: -: ..- . 0 1 s 3 yr. Lic.Nacc Aw MOnth Day Year Vacc. Serial (Lot) No. VAC0410001