Health Certificate Form "*" indicates required fields This form must be filled out in its entirety before health certificate can be issued. HORSE(S) *Please only list horses going to the same address and traveling on the same health certificate. If you are filling this form out for multiple owners you can list each horse with the owner’s name next to it. Example: Chance owned by Jane Doe. *Names must match what is listed on Coggins Test Result.*Horse NameOwner's Name Add RemoveAnticipated Date of travel:* Owner/Consignor'sName* First Last Phone Number:*Address* Street Address City State / Province / Region ZIP / Postal Code Recipient/Consignee's*Please list SAME if same as Owner/ConsignerName:* Phone Number:*Is Recipient/Consignee's address different from Owner/Consignor's address?* Yes No Address* Street Address City State / Province / Region ZIP / Postal Code Origin of HorseName of Property Owner or Barn: Phone Number:Address: Street Address City State / Province / Region ZIP / Postal Code Destination of HorseName of Property Owner or Barn: Phone Number:Address: Street Address City State / Province / Region ZIP / Postal Code Carrier/Shipper DetailsName of Carrier/Shipper: Phone Number:Address: Street Address City State / Province / Region ZIP / Postal Code
