STATE 



ALL VACCINATIONS MUST BE PROMPTLY REPORTED 

 COOPERATIVE STATE-FEDERAL BRUCELLOSIS ERADICATION PROGRAM Q 



BRUCELLOSIS VACCINATION „ s. DEPARTMENT OF AGRICULTURE 



RECORD ANIMAL AND PLANT HEALTH INSPECTION SERVICE 



VETERINARY SERVICES 



COUNTY ] CODE 



HERD NUMBER 



HERD OWNER LAST FIRST INITIAL 



VACCINE USED 



EXPIRATION DATE 



OWNER NUMBER 



ROUTE-STREET-ROAD 



SERIAL NUMBER 



DOSAGE 



Dfull 



□ REDUCED 



VACC TATTOO 



KINDOF HERD 



1 1 DAIRY Q BEEF Q MIXED 



POST OFFICE STATE ZIP CODE 



CERTIFICATION FOR PAYMENT 



[-1 FEDERAL [—1 ^||,s n ^^"^^^ H (oZ'^s^ 

 U EMPLOYEE LJ TFelron LJ COUNTY LJ g^'^/^ 



1 CERTIFY THAT; (1) 1 have vaccinated with 

 Strain 19 tattooed and eartacaed or otherwise 



REMARKS 



WBBS 



CV 



D 



AV 



n 



RGE 



TWP 



SEC 



DISTRICT 



FARM UNIT 



NO 



IDENTIFICATION 

 NUMBER 



AGE 



(MO-/ 

 YR) 



BREED 



SEX 



P/B- 

 GRADE 



• 

 TATTOO 



properly Identified all animals listed hereon as prescribed by the Brucellosis 

 UM & R, and recorded all information as prescribed by State regulations; 

 (2) when payment is claimed at program expense in accordance with agree- 

 ment number below no payment has been or will be received from any other 

 source. 



1 















2 















Signature 



Date of Vacci- 

 nation 



Agree. Code 



















3 



CERTIFICATION OF OWNER OR WITNESS 

















1 CERTIFY THAT the animals listed hereon were vaccinated and identified 

 for the above named owner. 



4 



Signature 



Date 



5 



















6 















CERTIFICATION FOR RE-ESTABLISHING VACCINATION STATUS 



• 1 1 indicate tattoo of animals previously vaccinated in appropriate column. 



7 















1 CERTIFY THAT 1 have personally examined the animal(s) noted hereon, and have 

 read the official tattoo(s) and have retagged them as shown. 



8 















Signature 



Date 



VS FORM 4-24 (AUG 831 



Previoiu edition may be lued. 



PART 1 -OFFICE 



16-7 



