Name*

First Last

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What date did you need your health certificate by?*

How do you want to receive your health certificate?*

Address in which the horse is located (if different from home)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

1.) Horse's Name*

Horse's Breed*

Horse's Date of Birth or Age*

Horse's Color

Horse's Gender*

Markings Face*

Markings Left Front*

Markings Right Front*

Markings Left Hind*

Markings Right Hind*

Tattoo or Brand*

Does this horse need a Coggins test?*

Where was the Coggins done?

2.) Horse's Name

Horse's Breed

Horse's Date of Birth or Age

Horse's Color

Horse's Gender

Markings Face

Markings Left Front

Markings Right Front

Markings Left Hind

Markings Right Hind

Tattoo or Brand

Does this horse need a Coggins test?

Where was the Coggins done?

3.) Horse's Name

Horse's Breed

Horse's Date of Birth or Age

Horse's Color

Horse's Gender

Markings Face

Markings Left Front

Markings Right Front

Markings Left Hind

Markings Right Hind

Tattoo or Brand

Does this horse need a Coggins test?

Where was the Coggins done?

Horse's Destination*

Purpose of transporting the horse.*

Date Leaving*

Destination Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Hauler's Name*

Hauler's Phone Number*

Equine Health Certificate Information Form

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