See reverse for more 0MB information. 



FORM APPROVED - 0MB NUMBER 0579 - 0127 



US DEPARTMENT OF AGRICULTURE 

 ANIMAL AND PLANT HEALTH INSPECTION SERVICE 



EQUINE INFECTIOUS ANEMIA LABORATORY TEST 



(VS Memorandum 555 16) 



SERIAL NO. 



I 



1. ACCESSION NUMBER 



2. DATE BLOOD 

 DRAWN 



Forms Without Adequate Descriptions Of The Horse and Complete Addresses Including Zip Codes, Counties, and Telephone 



Numbers Will Not Be Processed. 



3. REASON FOR TESTING Q Show 

 [^ Market Q Change of Ownership □ Retest 



D 



n 



First Test 

 Export 



7. NAME AND ADDRESS OR STABLE/MARKET (Please print or type) 



4. GEOGRAPHICINFORMATION 



5. VETERINARY LICENSE 

 OR ACCREDITATION NO. 



6. TEST TYPE 



□ ELISA 



□ AGIO 





SYSTEMS (GIS) 

 LAT 



Zip Code 



LONG: 



Tel No. 1 County 



8. NAME AND ADDRESS OF OWNER (Please pnnt or type) 



9. NAME AND ADDRESS OF VETERINARIAN (Please print or type) 











Zip Code 



Zip Code 



Tel No. 



County 









Tel No. I County 



CERTIFICATION OF FEDERALLY ACCREDITED VETERINARIAN 



I certify the specimen submitted with this Form was drawn by me from the horse described below on the date indicated above. 



10. SIGNATURE OF FEDERALLY ACCREDPTED VETERINARIAN 



11. TYPE OR PRINT SIGNATURE NAME 



12. SIGNATURE DATE 



CERTIFICATION OF OWNER OR OWNER'S AGENT 



I certify that I have examined this form and, to the best of my knowledge and belief, this form is true, conrect and complete. 



13. SIGNATURE OF OWNER OR OWNER'S AGENT 



14. TYPE OR PRINT SIGNATURE NAME 



15. SIGNATURE DATE 



16. 17. 



Tube Official 

 No. I Taa No. 



18. 

 Tattoo/Brand 



19. 

 Name of Horse 



20. 

 Color 



21. 

 Breed 



22. 



Electronic 



ID. No. 



23. 

 Age or 

 DOB 



M ■ Male 

 F - Female 

 G • Gelding 

 N - Neuter 



SHOW ALL SIGNIFICANT MARKINGS. WHORLS. BRANDS. AND SCARS 



1 - Coronet, 2 - Pastern, 3 - FetJock, 4 - Knee, 5 - Hock 



NARRATIVE DESCRIPTION AND REr\/IARKS 



25. MEAD 



26. OTHER MARKS AND BRANDS 



27. LEFTFORELIMB 



28. RIGHT FORELIMB 



29. LEFTHINDLIMB 



30. RIGHT HINDLIMB 



FOR LABORATORY USE ONLY 



31. LABORATORY NAME/CrrY/ST ATE 



32. DATE RECEIVED 



33. DATE REPORTED OUT 



36. SIGNATURE OF TECHNICIAN 



34. TEST RESULTS 



□ Negative Q Positive Q AGIO □ ELISA 



35. REMARKS 



Falsification of this form or knowingly using a falsified form is a criminal offense and may result In a fine of not more than $10,000 or imprisonment 



for not more than 5 years or both (U.S.C. Section 1001). 



VS FORM 10-11 (MAY 2003) 



16-27 



