Form 77 043 – Fill Out and Use This PDF

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of

No dog, cat, nonhuman primate, or additional kinds or classes of animals designated by

OMB APPROVED

information unless it displays a valid OMB control number. The valid OMB control numbers for this information collection are 0579-0020 and 0579-0036.

USDA regulations shall be delivered to any intermediate handler or carrier for transportation

0579-0020

The time required to complete this information collection is estimated to average .13 to .25 hours per response, including the time for reviewing instructions,

in commerce unless accompanied by a health certificate executed and issued by a licensed

0579-0036

searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

veterinarian (7 U.S.C. 21.43.9; CFR, Subchapter A, Part 2).

WARNING: Anyone who makes

1.

TYPE OF ANIMAL SHIPPED (select one only)

2. CERTIFICATE NUMBER - OFFICIAL USE ONLY

UNITED STATES DEPARTMENT OF AGRICULTURE

a false, fictitious, or fraudulent

Dog

Cat

Other_________________

ANIMAL AND PLANT HEALTH INSPECTION SERVICE

statement on this document, or

uses such document knowing it

Nonhuman Primate

Ferret

Rodent

UNITED STATES INTERSTATE AND INTERNATIONAL

to be false, fictitious, or

CERTIFICATE OF HEALTH EXAMINATION

fraudulent may be subject to a

3.

TOTAL NUMBER OF ANIMALS

4. PAGE

fine of not more than $10,000 or

FOR SMALL ANIMALS

imprisonment of not more than 5

years or both (18 U.S.C. 1001).

5. NAME, ADDRESS, AND TELEPHONE NUMBER OF OWNER (

CONSIGNOR)

6.

NAME, ADDRESS, AND TELEPHONE NUMBER OF RECIPIENT

AT DESTINATION (CONSIGNEE)

USDA License/or Registration Number (if applicable)

7. ANIMAL IDENTIFICATION

8. PERTINENT VACCINATION, TREATMENT, AND TESTING HISTORY

NAME, AND/OR TATTOO NUMBER

BREED – COMMON

COLOR OR

RABIES VACCINATION

OTHER VACCINATIONS,

OR SCIENTIFIC

AGE

SEX

DISTINCTIVE

TREATMENT, AND/OR TESTS AND RESULTS

OR OTHER IDENTIFICATION

MARKS OR

1 YEAR

2 YEARS

3 YEARS

NAME

MICROCHIP

Vaccination Date

Product

Date

Product Type and/or Results

(1)

(2)

(3)

(4)

(5)

(6)

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.

To my knowledge, the animal(s) described above and on continuation sheet(s) if applicable, originated from an area not quarantined

for rabies and has/have not been exposed to rabies.

ENDORSEMENT FOR INTERNATIONAL EXPORT (IF NEEDED)

NAME, ADDRESS, AND TELEPHONE NUMBER OF ISSUING VETERINARIAN

LICENSE NUMBER AND STATE

PRINTED NAME OF USDA VETERINARIAN

Accredited

Yes

No

If yes, please complete below

NATIONAL ACCREDITATION NUMBER

NOTE: International shipments may require certification by an accredited veterinarian.

SIGNATURE OF USDA VETERINARIAN Apply USDA Seal or Stamp here

DATE

SIGNATURE OF ISSUING VETERINARIAN

DATE

APHIS Form 7001

(NOV 2010)

This certificate is valid for 30 days after issuance