"Certificate of Independent Review and Completion of Trichomonosis Sample Collection and Evaluation Training" - California

Certificate of Independent Review and Completion of Trichomonosis Sample Collection and Evaluation Training is a legal document that was released by the California Department of Food & Agriculture - a government authority operating within California.

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cdfa
/
CALIFORNIA DEPARTMENT OF
FOOD
&
AGRICULTURE
Certificate of Independent Review and Completion of
Trichomonosis Sample Collection and Evaluation Training
I have viewed the video presentation, “Bovine Trichomonas Sampling: Sample
Collection Training for Veterinarians”, produced by CDFA and UC Davis School of
Veterinary Medicine. Furthermore, I am a USDA accredited veterinarian and have a
valid license to practice veterinary medicine in California.
______________________________________________________________________
Veterinarian
______________________________________________________________________
Clinic Name
_____________________________________________________________________
Address
(Home address if no clinic)
______________________________________________________________________
City, State, Zip Code, County
______________________________________________________________________
E-mail address
____________________ ____________________ ___________________________
Phone
Cell phone
Fax
___________________________________________
_____________________
Signature
Date
________________________
_______________________
CA License Number
License Expiration Date
________________________
_______________________
National Accreditation Number
Date Accredited
Please return form to your District Animal Health Branch Office.
Once this form is returned, a certificate will be issued from CDFA Animal Health Branch
Headquarters and will be mailed to address listed above.
J:\Livestock Health Management\Trichomonosis\Forms\SampleCollectionFormJan2016.docx
cdfa
/
CALIFORNIA DEPARTMENT OF
FOOD
&
AGRICULTURE
Certificate of Independent Review and Completion of
Trichomonosis Sample Collection and Evaluation Training
I have viewed the video presentation, “Bovine Trichomonas Sampling: Sample
Collection Training for Veterinarians”, produced by CDFA and UC Davis School of
Veterinary Medicine. Furthermore, I am a USDA accredited veterinarian and have a
valid license to practice veterinary medicine in California.
______________________________________________________________________
Veterinarian
______________________________________________________________________
Clinic Name
_____________________________________________________________________
Address
(Home address if no clinic)
______________________________________________________________________
City, State, Zip Code, County
______________________________________________________________________
E-mail address
____________________ ____________________ ___________________________
Phone
Cell phone
Fax
___________________________________________
_____________________
Signature
Date
________________________
_______________________
CA License Number
License Expiration Date
________________________
_______________________
National Accreditation Number
Date Accredited
Please return form to your District Animal Health Branch Office.
Once this form is returned, a certificate will be issued from CDFA Animal Health Branch
Headquarters and will be mailed to address listed above.
J:\Livestock Health Management\Trichomonosis\Forms\SampleCollectionFormJan2016.docx