Health Certificate Form

Name of Owner

First Name

Last Name

Current Home Premises of Equine

Ranch/Farm/Stable/Market

Registered Name

Barn Name if no Registered Name

Breed

Color

Gender

Markings

If no markings, write "none"

Date of Departure from Home Premises

Physical Address of Destination

NO P.O. BOXES

Name of Person Hauling

First Name

Last Name

Phone Number of the Person Hauling

(###)

###

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