Health Certificate HEALTH CERTIFICATE Consigner (seller / current owner)Name First Last PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Horse Origin (if different than cosignor)Barn Name Registered Name Facility Name Facility Contact PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Carrier InformationPurpose of Travel Date of Travel Month Day Year Carrier Type Carrier Name PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Consignee (buyer / receiving person)Name First Last PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Horse DestinationFacility Name Facility Contact PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CAPTCHA Δ
