Form IC-5 "Affidavit for Export From Guam to the State of Hawaii" - Hawaii

What Is Form IC-5?

This is a legal form that was released by the Hawaii Department of Agriculture - a government authority operating within Hawaii. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2003;
  • The latest edition provided by the Hawaii Department of Agriculture;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form IC-5 by clicking the link below or browse more documents and templates provided by the Hawaii Department of Agriculture.

ADVERTISEMENT
ADVERTISEMENT

Download Form IC-5 "Affidavit for Export From Guam to the State of Hawaii" - Hawaii

686 times
Rate (4.5 / 5) 49 votes
IC-5
Division of Animal Industry
(8/03)
99-941 Halawa Valley Street
Aiea, Hawaii 96701-5602
AFFIDAVIT FOR EXPORT FROM GUAM TO THE STATE OF HAWAII
(Original to Accompany Shipment)
STATEMENT OF OWNER OR CONSIGNOR
I hereby declare that the dog(s) or cat(s) that I am importing into Hawaii from Guam are described as:
1. ____________________, ___________, _____________________________, _________, ________________
(Color)
(Sex)
(Breed)
(Age)
(Pet's Name)
2. ____________________, ____________, _____________________________, ________, _________________
(Color)
(Sex)
(Breed)
(Age)
(Pet's Name)
I further declare that the above described animal(s) meets the following requirements:
A. Has not been outside of Guam during the six (6) month period immediately prior to the date of shipment to
Hawaii except to Australia, New Zealand, Great Britain or Hawaii.
B. Has been issued a health certificate by a veterinarian and countersigned by a veterinarian holding a
current appointment as an officer of the government of Guam prior to departure.
Owner or Consignor: ___________________________________________________ ______________________________
(Print or type FULL NAME)
SIGNATURE
Address: ________________________________________________________________ Date: _____________________
Consignee: ______________________________________________________________ Phone: (____)_______________
Address: ___________________________________________________________________________________________
CARRIER'S STATEMENT (To be completed on arrival by the Captain of the aircraft or senior station official of the
airlines based in Hawaii)
Flight No.: __________ Carrier: _______________________________ Date of Arrival: __________________________
Port of Origin: __________________________ Ports of Call: 1. ____________________ 2. ____________________
Transfer of animal(s) occurred:
FROM: Flight __________________; On (date and time) _____________________
TO:
Flight __________________; On (date and time) _____________________
I attest that the animals listed on this affidavit were carried onboard and transported from GUAM in one
aircraft and not off-loaded except as indicated above. I further attest that the above described animals
were not in direct contact with any other animal while in custody of this carrier.
SIGNATURE OF AIRLINE REPRESENTATIVE
TITLE
DATE
PRINT NAME
IC-5
Division of Animal Industry
(8/03)
99-941 Halawa Valley Street
Aiea, Hawaii 96701-5602
AFFIDAVIT FOR EXPORT FROM GUAM TO THE STATE OF HAWAII
(Original to Accompany Shipment)
STATEMENT OF OWNER OR CONSIGNOR
I hereby declare that the dog(s) or cat(s) that I am importing into Hawaii from Guam are described as:
1. ____________________, ___________, _____________________________, _________, ________________
(Color)
(Sex)
(Breed)
(Age)
(Pet's Name)
2. ____________________, ____________, _____________________________, ________, _________________
(Color)
(Sex)
(Breed)
(Age)
(Pet's Name)
I further declare that the above described animal(s) meets the following requirements:
A. Has not been outside of Guam during the six (6) month period immediately prior to the date of shipment to
Hawaii except to Australia, New Zealand, Great Britain or Hawaii.
B. Has been issued a health certificate by a veterinarian and countersigned by a veterinarian holding a
current appointment as an officer of the government of Guam prior to departure.
Owner or Consignor: ___________________________________________________ ______________________________
(Print or type FULL NAME)
SIGNATURE
Address: ________________________________________________________________ Date: _____________________
Consignee: ______________________________________________________________ Phone: (____)_______________
Address: ___________________________________________________________________________________________
CARRIER'S STATEMENT (To be completed on arrival by the Captain of the aircraft or senior station official of the
airlines based in Hawaii)
Flight No.: __________ Carrier: _______________________________ Date of Arrival: __________________________
Port of Origin: __________________________ Ports of Call: 1. ____________________ 2. ____________________
Transfer of animal(s) occurred:
FROM: Flight __________________; On (date and time) _____________________
TO:
Flight __________________; On (date and time) _____________________
I attest that the animals listed on this affidavit were carried onboard and transported from GUAM in one
aircraft and not off-loaded except as indicated above. I further attest that the above described animals
were not in direct contact with any other animal while in custody of this carrier.
SIGNATURE OF AIRLINE REPRESENTATIVE
TITLE
DATE
PRINT NAME