U.S. DEPARTMENT OF AGRICULTURE 

 ANIMAL AND PLANT HEALTH INSPECTION SERVICE 



OWNER/SHIPPER CERTIFICATE 

 FITNESS TO TRAVEL TO A SLAUGHTER FACILITY 



(Please type or print In Ink) 



According to the Paperwork Reduction Act of 1995, no persons 

 are required to respond to a collection of information unless it 

 displays a valid 0MB control number Tfie valid OIVIB control 

 number tor this information collection is 0579-0160. The time 

 required to complete this information collection is estimated to 

 average 5 min per response, including the time for reviewlno 

 instructions, searching existing data sources, gathering ana 

 maintaining the data needed, and completing and reviewing the 

 collection of information. 



FORM 



APPROVED 



0MB NO. 



0579-0160 



TIME HORSES LOADED ON CONVEYANCE ; DATE 



1 



CITY AND STATE WHERE HORSES WERE LOADED ON CONVEYANCE 



VEHICLE LICENSE NO. AND DRIVERS NAME 



NAME OF AUCTION/MARKET 



CONSIGNOR (OWNER/SHIPPER) NAME 



CONSIGNEE (RECEIVER/DESTINATION) NAME 



STREET ADDRESS 



STREET ADDRESS 



CITY. STATE. ZIP CODE 



CITY, STATE, ZIP CODE 



AREA CODE & TELEPHONE NO. 



AREA CODE & TELEPHONE NO. 



CHECK THE BOX THAT INDICATES THE FOLLOWING IS TRUE FOR ALL THE HORSES ON THIS CERTIFICATE 



I I Pregnant mares are not likely to foal (give birth) during the trip. Qj Horses are able to bear weight on all 4 limbs. 



I I Foals are older than 6 months o( age. (3] Horses are not blind in both eyes. 



Horses are able to walk unassisted. 





TAG 



Tag 



COLOR DESCRIPTION 



BREED/TYPE 



SEX 



BRANDS 

 Tattoos, etc. 



REMARKS Include 



1 PREFIX 1 NO. 



1 ' 



Bay 



Grey 



Blk. 



Pinto 



Chestn 



Other 



TB 



QT i Draft ! Pony 



Other 



Mare 



Sial 



Geld 



existing conditions 



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HORSES HAVE HAD ACCESS TO FOOD, WATER, AND REST FOR A MINIMUM OF 6 CONSECUTIVE 

 HOURS IMMEDIATELY BEFORE LOADING INTO CONVEYANCE. 



CANADIAN FOOD INSPECTION AGENCY (CFIA) 



EST. 



SIGNATURE 



DATE 





TIME 



1 HEREBY AUTHORIZE THE CFIA TO DISCLOSE THIS DOCUMENT AND THE INFORMATION IN IT AS 





COMPLETED BY THE CFIA OR DGIF TO THE USDA. 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 (18 U S C SECTION 1001) 



DIRECCION GENERAL DE INSPECCION EN 

 FRONTERAS (DGIF) 



EST. 



SIGNATURE OF OWNER/SHIPPER(l certify that the information contained in this form is true and correct to 

 the best of my knowledge.) 



DATE 





TIME 

































VS FORM 10-13 (AUG 2004) 



Previous editions are obslete 



PART 1 - INSPECTOR 



PAGE 1 OF , 



16-33 



