Health Certificate
Indiana Certificate of Veterinary Inspection
CONSIGNOR: Owner/Contact
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Phone Number
Please enter a valid phone number.
Location/Premise ID
CONSIGNEE: Destination (If animal is being sold to an individual)
First Name
Last Name
Show Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Disease Certification Statements Required by Show or State of Destination
Flock/Herd Number:
Flock/Herd Accredited Free For:
Rows
Tuberculosis
Brucellosis
Scrapie
NPIP
Johne's
PRV
CWD
Species
Official Permanent ID
Other ID (Registry Name, Ear Notch, Ear Tag, etc.)
Age (Specify Months or Years)
Breed
Gender
Please Select
Male
Female
Male Castrated
Name and Dates of Vaccines Administered
EIA Test Date, Lab, Test Result, Accession # (Horses Only)
Species
Official Permanent ID
Other ID (Registry Name, Ear Notch, Ear Tag, etc.)
Age (Specify Months or Years)
Breed
Gender
Please Select
Male
Female
Male Castrated
Name and Dates of Vaccines Administered
EIA Test Date, Lab, Test Result, Accession # (Horses Only)
Species
Official Permanent ID
Other ID (Registry Name, Ear Notch, Ear Tag, etc.)
Age (Specify Months or Years)
Breed
Gender
Please Select
Male
Female
Male Castrated
Name and Dates of Vaccines Administered
EIA Test Date, Lab, Test Result, Accession # (Horses Only)
Species
Official Permanent ID
Other ID (Registry Name, Ear Notch, Ear Tag, etc.)
Age (Specify Months or Years)
Breed
Gender
Please Select
Male
Female
Male Castrated
Name and Dates of Vaccines Administered
EIA Test Date, Lab, Test Result, Accession # (Horses Only)
Species
Official Permanent ID
Other ID (Registry Name, Ear Notch, Ear Tag, etc.)
Age (Specify Months or Years)
Breed
Gender
Please Select
Male
Female
Male Castrated
Name and Dates of Vaccines Administered
EIA Test Date, Lab, Test Result, Accession # (Horses Only)
Species
Official Permanent ID
Other ID (Registry Name, Ear Notch, Ear Tag, etc.)
Age (Specify Months or Years)
Breed
Gender
Please Select
Male
Female
Male Castrated
Name and Dates of Vaccines Administered
EIA Test Date, Lab, Test Result, Accession # (Horses Only)
Save
Submit
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