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Pet and Travel Information Form

Information the United States Department of Agriculture REQUIRES to Complete an Interstate and/or International Health Certificate

Please fill out the required fields below. We will be unable to complete your pet's Health Certificate without this information.

Pet's Name:*

Does your pet have a valid Pet Passport?*

Yes

No

Not Sure

If your pet has a valid Pet Passport, please state the country of origin:

Please provide your pet's microchip number below if known. If you do not know your pet's microchip number or are unsure if they have one, please write "Unknown." If your pet does not have a microchip, please write "N/A." Please note that some countries require pet's to have a microchip prior to vaccinations and/or entry.

Microchip Number:*

Pet's Age: (Please indicate age in either weeks, months or years)*

Pet's Sex:*

Species: (ie: Dog, Cat)*

Breed:

Coat Color/Pattern(s)/Marking(s):*

Date of Travel: (Estimate is ok if date not known)*

Method of Travel/Transportation: (ie: Airplane, Cargo Ship, Train, Car, etc.)*

Name of Airline: (or other method of transportation) (ie: American Airlines)*

City, State and Country of Departure:*

City, State and Country of Arrival:*

Reason for travel: (ie moving, vacation, etc)*

Are you planning on returning to the United States?*

Yes

No

Not Sure

Date or Estimated Date of Return to the United States: (If Applicable). Please note that depending on your date of return, you may need to have a health certificate re-issued by a veterinarian from the country you are traveling from to enter the United States with your pet.

First and Last Name of Recipient or Consignee: (if different from Owner)

Phone Number: (if different from Owner)

Email: (if different from Owner)

Address of Destination:*

Street Address:
Street Address Line 2:
City:
State/Province:
Postal Zip Code:
Country:

In order to complete your health certificate, please send your pet's current vaccination records, recent medical history, and proof of microchip (when applicable) to acgpvets@gmail.com for our veterinarian to review.

Our veterinarian will be in contact with you regarding scheduling and any additional requirements that will need to be met in order to complete your certificate's qualifications.

Please type your full name below as a signature of acknowledgment of the above statement.*

Full Name:
Date: