Health Certificate Request Download Form OwnerName* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* OriginName of Barn or Farm Origin*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneDate Leaving* HaulerHauler Information*Owner/Consignor HaulingPrivate/Commercial HaulerName First Last Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Hauler Phone NumberDestinationPlease visit the Department of Agriculture to view individual state requirements for legal entry and interstate travel. You may click here or call our office to request information regarding international travel.Add Additional Destinations1st Destination2nd DestinationName of Destination or Contact*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Purpose of the tripMovingTransfer of Ownership/SaleBreedingTrainingShow/ExibitionPleasureRodeo or CircusOtherPhoneName of Destination or Contact*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Purpose of the tripMovingTransfer of Ownership/SaleBreedingTrainingShow/ExibitionPleasureRodeo or CircusOtherPhoneHorsePlease note that all horses must be listed separately on the Health Certificate with the exception of foals under the age of 6 months that have not yet been weaned; such foals can be listed as "foal by side" and consequently do not require their own coggins test.Number Of Horses1 Horse2 Horses3 Horses4 Horses5 Horses1. Horse Barn/Registered NameHas this horse been seen by Mid-Rivers Equine Centre within the past 30 days?YesNoAge*Age Cont.Month(s)Year(s)BreedColorSexMareStallionGeldingFoal up to 6 months old SucklingCoggins Location*Mid-Rivers Equine Centre (MREC) CogginsCoggins was not performed by MRECPlease note that all horses must have a valid negative EIA or Coggins test for legal interstate travel, please visit the Department of Agriculture to view individual state requirements. Upload Negative Coggins Test2. Horse Barn/Registered NameHas this horse been seen by Mid-Rivers Equine Centre within the past 30 days?YesNoAge*Age Cont.Month(s)Year(s)BreedColorSexMareStallionGeldingFoal up to 6 months old SucklingHorse Coggins Location*Mid-Rivers Equine Centre (MREC) CogginsCoggins was not performed by MRECUpload Negative Coggins Test3. Horse Barn/Registered NameHas this horse been seen by Mid-Rivers Equine Centre within the past 30 days?YesNoAge*Age Cont.Month(s)Year(s)BreedColorSexMareStallionGeldingFoal up to 6 months old SucklingHorse Coggins Location*Mid-Rivers Equine Centre (MREC) CogginsCoggins was not performed by MRECUpload Negative Coggins Test4. Horse Barn/Registered NameHas this horse been seen by Mid-Rivers Equine Centre within the past 30 days?YesNoAge*Age Cont.Month(s)Year(s)BreedColorSexMareStallionGeldingFoal up to 6 months old SucklingDate of Blood Draw Date Reported Horse Coggins Location*Mid-Rivers Equine Centre (MREC) CogginsCoggins was not performed by MRECUpload Negative Coggins Test5. Horse Barn/Registered NameHas this horse been seen by Mid-Rivers Equine Centre within the past 30 days?YesNoAge*Age Cont.Month(s)Year(s)BreedColorSexMareStallionGeldingFoal up to 6 months old SucklingHorse Coggins Location*Mid-Rivers Equine Centre (MREC) CogginsCoggins was not performed by MRECUpload Negative Coggins TestMedical HistoryVaccination History (for each horse listed)Prior Destination(s) in the Past 30 Days (for each horse listed)Please note that we cannot complete a Health Certificate without all of the required information as it pertains to each destination. I understand this is a REQUEST FOR HEALTH CERTIFICATE ONLY.* Yes CAPTCHA