AH-010 (rev. 1/19)
MICHIGAN DEPARTMENT OF AGRICULTURE AND RURAL DEVELOPMENT
ANIMAL INDUSTRY DIVISION
P.O. Box 30017, Lansing, MI 48909-8276
Phone: 800-292-3939
Fax: 517-241-1560
In accordance with Act 287, PA 1969 as amended
MICHIGAN PET HEALTH CERTIFICATE
Eachpetshoporlarge‐scaledogbreedingkennelshallnotsell,exchange,transfer,ordeliveradog,cat,orferretwithoutprovidingtothepurchaseravalidpethealthcertificateforeachanimal.
ThisMichiganPetHealthCertificateisonlyvalidfor30daysafterthedatetheanimalwasexaminedbytheveterinarianwhosignedthecertificate.
PetShoporLarge‐ScaleDogBreedingKennelInformation
FullLegalNameoftheaboveBusiness: ContactPerson: Title:
PhysicalAddress(P.O.Boxesarenotaccepted): City: Zipcode:
County: BusinessPhone: BusinessEmail:
Mailingaddressifdifferentfromabove,StreetorP.O.Box: City: State: Zipcode:
AnimalInformation
AnimalIdentification(check/fillinallidentification(ID)theanimalhas):
Name:Microchip#: Tattoo#: OtherID#:
AnimalSpecies: Breed(s): Sex:
MaleFemale Intact?Y N
Color(s): Age:(weeks,months,years/DateofBirth)
weeks months yrs
DateofBirth:
ApproximateWeight:
ExaminingVeterinarianInformationforThisAnimal
Medicalconditions(list):
Noneknown
Vaccination(s)andmedicaltreatment(s)receivedbythisanimalwhileunderthecontrolofthisPetShoporLarge‐ScaleDogBreedingKennel,ifknown,arelistedbelow:
Noneknown
VaccinatedAgainst Date(s) ProductName VaccineManufacturer
TreatmentAdministered Date(s) Product/DrugAdministered WhyAdministered
Additional vaccinations/treatments for this animal are listed on page 2. BysigningbelowIcertifythattheforegoingistrueandaccuratetothebestofmyknowledgeandbelief.
Iherebycertify thatIhaveexaminedthisanimalonthisdateandatthetimeofthepreparationofthiscertificate;Ifoundthisanimalfreefromvisualevidenceofcommunicabledisease.
SignatureofExaminingVeterinarian: ExaminationDate: MichiganVeterinarianLicenseNo:
PrintedNameofExaminingVeterinarian: VeterinaryPracticeBusinessName(ifapplicable):
PracticeAddress: City: State: Zipcode:
County: BusinessPhone: BusinessEmail:
PurchaserInformation
NameofIndividual/Business/Organization: Forbusiness/organization,thepersontakingreceiptofthisanimalontheirbehalf:
Individual/Business/OrganizationAddress: City: State: Zipcode:
Phone: DateofPurchase: Email:
SignatureofPurchaserorBusiness/Organizationrepresentative: TitleofBusiness/Organizationrepresentative:
THIS CERTIFICATE EXPIRES 30 DAYS AFTER THE VETERINARIAN EXAMINATION DATE
Original–Purchaser
Copy‐PetShop/LDBK
Copy–IssuingVeterinarian
ThisisnotanOfficialInterstateCertificateof
VeterinaryInspection(ICVI).ThisCertificate
isvalidfor30daysaftertheveterinarian
examinationdate.
If additional vaccinations and/or treatments were administered, please check box above, and continue by using page 2 of this form