Aphis Form 7001

ENDORSEMENT FOR INTERNATIONAL EXPORT IF NEEDED PRINTED NAME OF USDA VETERINARIAN LICENSE NUMBER AND STATE Accredited Yes No If yes please complete below NATIONAL ACCREDITATION NUMBER SIGNATURE OF USDA VETERINARIAN APHIS Form 7001 NOV 2010 Apply USDA Seal or Stamp here DATE NOTE International shipments may require certification by an accredited veterinarian. SIGNATURE OF ISSUING VETERINARIAN This certificate is valid for 30 days after issuance. 25 h ours per r esponse i ncluding the ti me for rev iewing in structions searching existing data sources gathering and maintaining the data needed and completing and reviewing the collection of information. UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE UNITED STATES INTERSTATE AND INTERNATIONAL CERTIFICATE OF HEALTH EXAMINATION FOR SMALL ANIMALS WARNING Anyone who makes a false fictitious or fraudulent statement on this document or uses such document knowing it to be false fictitious or fraudulent may be subject to a fine of not more than 10 000 or imprisonment of not more than 5 years or both 18 U.S.C. According to t he P aperwork R eduction Act o f 1995 an ag ency ma y not cond uct or sponsor an d a p erson i s not r equired to r espond to a c ollection of information unless it displays a valid OMB control number. The valid OMB control numbers for this information collection are 0579-0036 and 0579-0333. The ti me r equired to complete t his i nformation col lection i s esti mated t o av erage. 1001. 5. NAME ADDRESS AND TELEPHONE NUMBER OF OWNER CONSIGNOR 1. TYPE OF ANIMAL SHIPPED select one only Dog Cat BREED COMMON OR SCIENTIFIC NAME OMB APPROVED 0579-0036 0579-0333 2. CERTIFICATE NUMBER - OFFICIAL USE ONLY Other Nonhuman Primate Ferret Rodent 3. TOTAL NUMBER OF ANIMALS 4. PAGE USDA License/or Registration Number if applicable 7. ANIMAL IDENTIFICATION NAME AND/OR TATTOO NUMBER OR OTHER IDENTIFICATION No dog cat nonhuman primate or additional kinds or classes of animals designated by USDA r egulation sh all be del ivered to any i ntermediate handler or car rier for transportation i n com merce u nless acco mpanied by a heal th ce rtificate ex ecuted a nd issued by a licensed veterinarian 7 U*S*C. 21. 43. 9 CFR Subchapter A Part 2. 8. PERTINENT VACCINATION TREATMENT AND TESTING HISTORY AGE SEX COLOR OR DISTINCTIVE MARKS OR MICROCHIP RABIES VACCINATION 1 YEAR 2 YEARS Vaccination Date OTHER VACCINATIONS TREATMENT AND/OR TESTS AND RESULTS Product Date Product Type and/or Results 9. REMARKS OR ADDITIONAL CERTIFICATION STATEMENTS WHEN REQUIRED VETERINARY CERTIFICATION I certify that the animals described in box 7 have been examined by me this date that the information provided in box 8 is true and accurate to the best of my knowledge and that the following findings have been made X applicable statements. I have verified the presence of the microchip if a microchip is listed in box 7. I certify that the animal s described above and on continuation sheet s if applicable have been inspected by me on this date and appear to be free of any infectious or contagious diseases and to the best of my knowledge exposure thereto which would endanger the animal or other animals or would endanger public health.