Dog Seller Record Form Template



AH-DS-700..docx 2/18Personal information you provide may be used for purposes other than that for which it was originally collected – sec.15.04 (1)(m), Wis. Stats.338782921000Wisconsin Department of Agriculture, Trade and Consumer ProtectionDivision of Animal HealthPO Box 8911, Madison, WI 53708-8911 Phone: (608) 224-4872 Fax (608) 224-4871Dog Seller Program Record Form Templatess. ATCP 16.14 (3) (a) – (i) and s. 173.41 (11), Wis. Stats.SECTION A: DOG INFORMATIONDOG NAME (if any) FORMTEXT ?????DOB / APPROX. AGE FORMTEXT ?????SEX FORMCHECKBOX F FORMCHECKBOX MBREED FORMTEXT ?????COLOR & MARKINGS FORMTEXT ?????USDA ID (if any) AND/OR FORMTEXT ?????OTHER ID: FORMTEXT ?????TATTOO FORMTEXT ?????Born under license holders custody? If NO fill in Sec. B FORMCHECKBOX YES FORMCHECKBOX NOSECTION B: ACQUIRED FROM INFORMATION (if any) of person the dog was acquired fromDATE FORMTEXT ?????NAME FORMTEXT ?????STREET ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ??ZIP FORMTEXT ?????USDA LICENSE # (if any) FORMTEXT ?????SECTION C: DISPOSITION INFORMATION (if any) of person the dog was transferred toDISPOSITION UPON: FORMCHECKBOX TRANSFER FORMCHECKBOX EUTHANSIA FORMCHECKBOX DEATH FORMCHECKBOX OTHER: FORMTEXT ?????DATE FORMTEXT ?????NAME FORMTEXT ?????STREET ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ??ZIP FORMTEXT ?????USDA LICENSE # (if any) FORMTEXT ?????SECTION A: DOG INFORMATIONDOG NAME (if any) FORMTEXT ?????DOB / APPROX. AGE FORMTEXT ?????SEX FORMCHECKBOX F FORMCHECKBOX MBREED FORMTEXT ?????COLOR & MARKINGS FORMTEXT ?????USDA ID (if any) AND/OR FORMTEXT ?????OTHER ID: FORMTEXT ?????TATTOO FORMTEXT ?????Born under license holders custody? If NO fill in Sec. B FORMCHECKBOX YES FORMCHECKBOX NOSECTION B: ACQUIRED FROM INFORMATION (if any) of person the dog was acquired fromDATE FORMTEXT ?????NAME FORMTEXT ?????STREET ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ??ZIP FORMTEXT ?????USDA LICENSE # (if any) FORMTEXT ?????SECTION C: DISPOSITION INFORMATION (if any) of person the dog was transferred toDISPOSITION UPON: FORMCHECKBOX TRANSFER FORMCHECKBOX EUTHANSIA FORMCHECKBOX DEATH FORMCHECKBOX OTHER: FORMTEXT ?????DATE FORMTEXT ?????NAME FORMTEXT ?????STREET ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ??ZIP FORMTEXT ?????USDA LICENSE # (if any) FORMTEXT ?????SECTION A: DOG INFORMATIONDOG NAME (if any) FORMTEXT ?????DOB / APPROX. AGE FORMTEXT ?????SEX FORMCHECKBOX F FORMCHECKBOX MBREED FORMTEXT ?????COLOR & MARKINGS FORMTEXT ?????USDA ID (if any) AND/OR FORMTEXT ?????OTHER ID: FORMTEXT ?????TATTOO FORMTEXT ?????Born under license holders custody? If NO fill in Sec. B FORMCHECKBOX YES FORMCHECKBOX NOSECTION B: ACQUIRED FROM INFORMATION (if any) of person the dog was acquired fromDATE FORMTEXT ?????NAME FORMTEXT ?????STREET ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ??ZIP FORMTEXT ?????USDA LICENSE # (if any) FORMTEXT ?????SECTION C: DISPOSITION INFORMATION (if any) of person the dog was transferred toDISPOSITION UPON: FORMCHECKBOX TRANSFER FORMCHECKBOX EUTHANSIA FORMCHECKBOX DEATH FORMCHECKBOX OTHER: FORMTEXT ?????DATE FORMTEXT ?????NAME FORMTEXT ?????STREET ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ??ZIP FORMTEXT ?????USDA LICENSE # (if any) FORMTEXT ?????SECTION A: DOG INFORMATIONDOG NAME (if any) FORMTEXT ?????DOB / APPROX. AGE FORMTEXT ?????SEX FORMCHECKBOX F FORMCHECKBOX MBREED FORMTEXT ?????COLOR & MARKINGS FORMTEXT ?????USDA ID (if any) AND/OR FORMTEXT ?????OTHER ID: FORMTEXT ?????TATTOO FORMTEXT ?????Born under license holders custody? If NO fill in Sec. B FORMCHECKBOX YES FORMCHECKBOX NOSECTION B: ACQUIRED FROM INFORMATION (if any) of person the dog was acquired fromDATE FORMTEXT ?????NAME FORMTEXT ?????STREET ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ??ZIP FORMTEXT ?????USDA LICENSE # (if any) FORMTEXT ?????SECTION C: DISPOSITION INFORMATION (if any) of person the dog was transferred toDISPOSITION UPON: FORMCHECKBOX TRANSFER FORMCHECKBOX EUTHANSIA FORMCHECKBOX DEATH FORMCHECKBOX OTHER: FORMTEXT ?????DATE FORMTEXT ?????NAME FORMTEXT ?????STREET ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ??ZIP FORMTEXT ?????USDA LICENSE # (if any) FORMTEXT ????? ................
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