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* MM slash DD slash YYYY 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 Destinations 1st Destination 2nd Destination Name 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 Horses 1 Horse 2 Horses 3 Horses 4 Horses 5 Horses 1. Horse Barn/Registered Name On what date did a Mid-Rivers veterinarian last see this horse? MM slash DD slash YYYY Age* Age Cont.Month(s)Year(s)Breed Color SexMareStallionGeldingFoal 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 TestMax. file size: 8 MB.2. Horse Barn/Registered Name On what date did a Mid-Rivers veterinarian last see this horse? MM slash DD slash YYYY Age* Age Cont.Month(s)Year(s)Breed Color SexMareStallionGeldingFoal up to 6 months old SucklingHorse Coggins Location*Mid-Rivers Equine Centre (MREC) CogginsCoggins was not performed by MRECUpload Negative Coggins TestMax. file size: 8 MB.3. Horse Barn/Registered Name On what date did a Mid-Rivers veterinarian last see this horse? MM slash DD slash YYYY Age* Age Cont.Month(s)Year(s)Breed Color SexMareStallionGeldingFoal up to 6 months old SucklingHorse Coggins Location*Mid-Rivers Equine Centre (MREC) CogginsCoggins was not performed by MRECUpload Negative Coggins TestMax. file size: 8 MB.4. Horse Barn/Registered Name On what date did a Mid-Rivers veterinarian last see this horse? MM slash DD slash YYYY Age* Age Cont.Month(s)Year(s)Breed Color SexMareStallionGeldingFoal up to 6 months old SucklingDate of Blood Draw MM slash DD slash YYYY Date Reported MM slash DD slash YYYY Horse Coggins Location*Mid-Rivers Equine Centre (MREC) CogginsCoggins was not performed by MRECUpload Negative Coggins TestMax. file size: 8 MB.5. Horse Barn/Registered Name On what date did a Mid-Rivers veterinarian last see this horse? MM slash DD slash YYYY Age* Age Cont.Month(s)Year(s)Breed Color SexMareStallionGeldingFoal up to 6 months old SucklingHorse Coggins Location*Mid-Rivers Equine Centre (MREC) CogginsCoggins was not performed by MRECUpload Negative Coggins TestMax. file size: 8 MB.Medical 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