Disclosure Form for Pet Shop Operators - Illinois

This printable "Disclosure Form for Pet Shop Operators" is a document issued by the Illinois Department of Agriculture specifically for Illinois residents.

Download a PDF of the latest edition of the form down below or find it through the department's forms library.

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Name (Pet Shop)
Address
City, State, Zip
Telephone
AW License ID #
Disclosures
Date Received:
Cage/Kennel Number: _________ Breed:
Color: ______________
Age:
Date of Birth: ___________
Sex: M F NM SF
Spay/Neuter Date: _________
Price: _________ Other Fees & Charges: ____________
Microchip#:
Breeder Name: ___________________________________
Illinois License # _____________
Mailing Address: _________________________________
USDA License # _____________
City, State, Zip: __________________________________
Congenital/hereditary disease of parents or offspring, if any: __________________________________________________
Pedigree Registration: Sire #_______________________ Dam #___________________________
Address of pedigree registry: ____________________________________________________________________________
If dog or cat returned by customer, date and reason for return: __________________________________________________
Inoculations and treatments of this animal since the date received:
Vaccinations/Inoculations
Diagnostic Tests
Inoculations and Treatments of this animal since the date received by pet store:
Product
Date
Date
Results
Rabies
________________
___________
Fecal
___________
_______
K-9 Distemper/Parvo
________________
___________
Parvo
___________
_______
FVRCP
________________
___________
Heartworm ___________
_______
FELV
________________
___________
FELV/FIV
___________
_______
Bordetella
________________
___________
Other
___________
_______
___________
___________
_______
Other
________________
___________
Dewormers/Medications
Dosage
Date
Date
Date
Date
Date
Date
Date
Date
Additional information may be included on a separate sheet
Remarks:
A copy of our policy regarding warranties, refunds, or returns is available upon request.
Acknowledgement of Disclosures
I hereby attest that all of the above information is true and correct to the best of my knowledge.
___________________________
______________
(Pet Shop) Staff: ___________________________
Print Name
Signature
Date
I hereby attest that this disclosure was posted on or near the cage of the dog or cat for sale and that I have read all the
disclosures. I further understand that I am entitled to keep a signed copy of this disclosure.
___________________________
______________
Customer: ________________________________
Print Name
Signature
Date
Original: Pet Shop
Copy: Customer
Name (Pet Shop)
Address
City, State, Zip
Telephone
AW License ID #
Disclosures
Date Received:
Cage/Kennel Number: _________ Breed:
Color: ______________
Age:
Date of Birth: ___________
Sex: M F NM SF
Spay/Neuter Date: _________
Price: _________ Other Fees & Charges: ____________
Microchip#:
Breeder Name: ___________________________________
Illinois License # _____________
Mailing Address: _________________________________
USDA License # _____________
City, State, Zip: __________________________________
Congenital/hereditary disease of parents or offspring, if any: __________________________________________________
Pedigree Registration: Sire #_______________________ Dam #___________________________
Address of pedigree registry: ____________________________________________________________________________
If dog or cat returned by customer, date and reason for return: __________________________________________________
Inoculations and treatments of this animal since the date received:
Vaccinations/Inoculations
Diagnostic Tests
Inoculations and Treatments of this animal since the date received by pet store:
Product
Date
Date
Results
Rabies
________________
___________
Fecal
___________
_______
K-9 Distemper/Parvo
________________
___________
Parvo
___________
_______
FVRCP
________________
___________
Heartworm ___________
_______
FELV
________________
___________
FELV/FIV
___________
_______
Bordetella
________________
___________
Other
___________
_______
___________
___________
_______
Other
________________
___________
Dewormers/Medications
Dosage
Date
Date
Date
Date
Date
Date
Date
Date
Additional information may be included on a separate sheet
Remarks:
A copy of our policy regarding warranties, refunds, or returns is available upon request.
Acknowledgement of Disclosures
I hereby attest that all of the above information is true and correct to the best of my knowledge.
___________________________
______________
(Pet Shop) Staff: ___________________________
Print Name
Signature
Date
I hereby attest that this disclosure was posted on or near the cage of the dog or cat for sale and that I have read all the
disclosures. I further understand that I am entitled to keep a signed copy of this disclosure.
___________________________
______________
Customer: ________________________________
Print Name
Signature
Date
Original: Pet Shop
Copy: Customer

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