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
Eachpetshoporlarge‐scaledogbreedingkennelshallnotsell,exchange,transfer,ordeliveradog,cat,orferretwithoutprovidingtothepurchaseravalidpethealthcertificateforeachanimal.
ThisMichiganPetHealthCertificateisonlyvalidfor30daysafterthedatetheanimalwasexaminedbytheveterinarianwhosignedthecertificate.
PetShoporLarge‐ScaleDogBreedingKennelInformation
FullLegalNameoftheaboveBusiness: ContactPerson: Title:
PhysicalAddress(P.O.Boxesarenotaccepted): City: Zipcode:
County: BusinessPhone: BusinessEmail:
Mailingaddressifdifferentfromabove,StreetorP.O.Box: City: State: Zipcode:
AnimalInformation
AnimalIdentification(check/fillinallidentification(ID)theanimalhas):
Name:Microchip#: Tattoo#: OtherID#:
AnimalSpecies: Breed(s): Sex:
MaleFemale Intact?Y N
Color(s): Age:(weeks,months,years/DateofBirth)
weeks months  yrs
DateofBirth:
ApproximateWeight:
ExaminingVeterinarianInformationforThisAnimal
Medicalconditions(list):
Noneknown
Vaccination(s)andmedicaltreatment(s)receivedbythisanimalwhileunderthecontrolofthisPetShoporLarge‐ScaleDogBreedingKennel,ifknown,arelistedbelow:
Noneknown
VaccinatedAgainst Date(s) ProductName VaccineManufacturer
TreatmentAdministered Date(s) Product/DrugAdministered WhyAdministered
Additional vaccinations/treatments for this animal are listed on page 2. BysigningbelowIcertifythattheforegoingistrueandaccuratetothebestofmyknowledgeandbelief.
Iherebycertify thatIhaveexaminedthisanimalonthisdateandatthetimeofthepreparationofthiscertificate;Ifoundthisanimalfreefromvisualevidenceofcommunicabledisease.
SignatureofExaminingVeterinarian: ExaminationDate: MichiganVeterinarianLicenseNo:
PrintedNameofExaminingVeterinarian: VeterinaryPracticeBusinessName(ifapplicable):
PracticeAddress: City: State: Zipcode:
County: BusinessPhone: BusinessEmail:
PurchaserInformation
NameofIndividual/Business/Organization: Forbusiness/organization,thepersontakingreceiptofthisanimalontheirbehalf:
Individual/Business/OrganizationAddress: City: State: Zipcode:
Phone: DateofPurchase: Email:
SignatureofPurchaserorBusiness/Organizationrepresentative: TitleofBusiness/Organizationrepresentative:
THIS CERTIFICATE EXPIRES 30 DAYS AFTER THE VETERINARIAN EXAMINATION DATE
Original–Purchaser
Copy‐PetShop/LDBK
Copy–IssuingVeterinarian
ThisisnotanOfficialInterstateCertificateof
VeterinaryInspection(ICVI).ThisCertificate
isvalidfor30daysaftertheveterinarian
examinationdate.
If additional vaccinations and/or treatments were administered, please check box above, and continue by using page 2 of this form
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– Page 2 (continuation)
Each pet shop or large-scale dog breeding kennel shall not sell, exchange, transfer, or deliver a dog, cat, or ferret without providing to the purchaser a valid pet health certificate for each animal.
This Michigan Pet Health Certificate is only valid for 30 days after the date the animal was examined by the veterinarian who signed the certificate.
Animal Information (continued from page 1)
Animal Identification (check/fill in all identification (ID) the animal has):
Name: Microchip #:
Tattoo #: Other ID #:
Examining Veterinarian Information for This Animal (in addition to the treatments/vaccinations from page 1)
Vaccination(s) and medical treatment(s) received by this animal while under the control of this Pet Shop or Large-Scale Dog Breeding Kennel, if known, are listed below:
Vaccinated Against
Date(s)
Product Name
Vaccine Manufacturer
Treatment Administered
Date(s)
Product/Drug Administered
Why Administered
By signing below, I certify that the foregoing is true and accurate to the best of my knowledge and belief. I hereby certify that I have examined this animal on this date and at the time of the
preparation of this certificate; I found this animal free from visual evidence of communicable disease.
Signature of Examining Veterinarian:
Printed Name of Examining Veterinarian
Original – Purchaser
Copy - Pet Shop/LDBK
Copy – Issuing Veterinarian
This is not an Official Interstate Certificate of
Veterinary Inspection (ICVI). This Certificate
is valid for 30 days after the veterinarian
examination date.