CONTACT:
Florida Department of Agriculture and Consumer Services
Division of Animal Industry
Florida Department of Agriculture
and Consumer Services
Bureau of Animal Disease Control
Division of Animal Industry
Cervidae Programs Office
407 S. Calhoun St., MS 7
REQUEST FOR
Tallahassee, FL 32399-0800
ADAM H. PUTNAM
TUBERCULOSIS QUALIFIED STATUS
COMMISSIONER
850/410-0900 Fax: 410-0957
FOR CERVIDAE
www.FreshFromFlorida.com/ai
§ 585.145, Florida Statutes
Note: All documents and attachments submitted with this request are subject to public review pursuant to
Chapter 119, F.S.
A. HERD OWNER INFORMATION
I, the undersigned, do hereby make request for issuance of Tuberculosis Qualified Status of my Cervidae herd at
Premises Name
County
By affixing my signature below, I certify that my herd, presently consisting of
test eligible
Number of Eligible Animals
Species
Has been maintained and tested in full accordance with the Uniform Methods and Rules for Bovine Tuberculosis Eradication, Part IV - Captive
Cervids (APHIS 91-45-011) and Cervidae Movement, 5C-26, Florida Administrative Code.
All additions have been natural additions and/or brought into the herd in compliance with the Uniform Methods and Rules for Bovine Tuberculosis
Eradication, Part IV - Captive Cervids ( APHIS 91-45-011) and Cervidae Movement, 5C-26, Florida Administrative Code.
(
Premises GPS
5 decimal digits)
Latitude
Longitude
Premises ID Number
Owner Signature
Owner Name (Printed)
Owner Mailing Address
Owner Phone Number
B. CERTIFICATION BY TESTING VETERINARIAN
The above named owner’s statement is true to the best of my knowledge, and I HEREBY CERTIFY THAT ALL ELIGIBLE ANIMALS
IN THIS HERD HAVE BEEN TESTED.
Approval of this request is recommended.
Accredited Veterinarian’s Name (Printed)
Accredited Veterinarian’s Signature
Veterinary Clinic Name
Clinic Address
Clinic City, State, ZipCode
Clinic Phone Number
FDACS-09116 Rev. 05/13
Page 1 of 2
CONTACT:
Florida Department of Agriculture and Consumer Services
Division of Animal Industry
Florida Department of Agriculture
and Consumer Services
Bureau of Animal Disease Control
Division of Animal Industry
Cervidae Programs Office
407 S. Calhoun St., MS 7
REQUEST FOR
Tallahassee, FL 32399-0800
ADAM H. PUTNAM
TUBERCULOSIS QUALIFIED STATUS
COMMISSIONER
850/410-0900 Fax: 410-0957
FOR CERVIDAE
www.FreshFromFlorida.com/ai
§ 585.145, Florida Statutes
Note: All documents and attachments submitted with this request are subject to public review pursuant to
Chapter 119, F.S.
A. HERD OWNER INFORMATION
I, the undersigned, do hereby make request for issuance of Tuberculosis Qualified Status of my Cervidae herd at
Premises Name
County
By affixing my signature below, I certify that my herd, presently consisting of
test eligible
Number of Eligible Animals
Species
Has been maintained and tested in full accordance with the Uniform Methods and Rules for Bovine Tuberculosis Eradication, Part IV - Captive
Cervids (APHIS 91-45-011) and Cervidae Movement, 5C-26, Florida Administrative Code.
All additions have been natural additions and/or brought into the herd in compliance with the Uniform Methods and Rules for Bovine Tuberculosis
Eradication, Part IV - Captive Cervids ( APHIS 91-45-011) and Cervidae Movement, 5C-26, Florida Administrative Code.
(
Premises GPS
5 decimal digits)
Latitude
Longitude
Premises ID Number
Owner Signature
Owner Name (Printed)
Owner Mailing Address
Owner Phone Number
B. CERTIFICATION BY TESTING VETERINARIAN
The above named owner’s statement is true to the best of my knowledge, and I HEREBY CERTIFY THAT ALL ELIGIBLE ANIMALS
IN THIS HERD HAVE BEEN TESTED.
Approval of this request is recommended.
Accredited Veterinarian’s Name (Printed)
Accredited Veterinarian’s Signature
Veterinary Clinic Name
Clinic Address
Clinic City, State, ZipCode
Clinic Phone Number
FDACS-09116 Rev. 05/13
Page 1 of 2
REQUEST FOR TUBERCULOSIS QUALIFIED STATUS FOR CERVIDAE (Continued)
C. RECORD OF TUBERCULOSIS TESTING
DATE
ANIMAL NUMBER
RESULTS/COMMENTS
** PLEASE ATTACH TUBERCULOSIS TEST CHARTS
Owner & Herd Name
Accredited Veterinarian Signature
D. PURCHASED ADDITIONS
DATE OF ACQUISITION
SPECIES/SEX
SOURCE HERD/LOCATION
Owner & Herd Name
Accredited Veterinarian Signature
FDACS-09116 Rev. 05/13
Page 2 of 2