According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection 

of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0579-0036. The time 

required to complete this information collection is estimated to average .25 hours per response, including the time for reviewing instructions, searching 

existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

OMB APPROVED

0579-0036

UNITED STATES DEPARTMENT OF AGRICULTURE

ANIMAL AND PLANT HEALTH INSPECTION SERVICE

ANIMAL CARE

LIVE DOG IMPORT

HEALTH AND RABIES CERTIFICATE

NAME OF THE PERSON INTENDING TO IMPORT THE DOG INTO THE UNITED STATES:

ADDRESS: CITY: STATE: ZIP CODE:

PHONE NUMBER (including country code): EMAIL ADDRESS:

IDENTIFICATION OF DOG

BREED SEX

DATE OF

BIRTH

(MMM DD, YYYY)

COLOR MICROCHIP NUMBER OTHER IDENTIFYING INFORMATION

(e.g., name, markings, tattoo, tag number)

VACCINATION INFORMATION - GENERAL

PRODUCT NAME MANUFACTURER

LOT NUMBER AND LOT 

EXPIRATION DATE

(MM/DD/YYYY)

DATE OF VACCINATION

(MMM DD, YYYY)

DATE OF EXPIRATION 

OF VACCINATION

(MMM DD, YYYY)

VACCINATION INFORMATION – RABIES

PRODUCT NAME MANUFACTURER

LOT NUMBER AND LOT 

EXPIRATION DATE 

(MM/DD/YYYY)

DATE OF VACCINATION

(if initial vaccine, must be

given 30 days prior to entry

in the U.S.) (MMM DD, YYYY)

DATE OF EXPIRATION 

OF VACCINATION

(MMM DD, YYYY)

Veterinary Certificate

1. I certify that the dog identified above was examined by me on this date and that the information on this form is true and correct.

2. I certify that I hold a valid license to practice veterinary medicine in the country of export.

3. The dog listed above appears to be healthy upon examination and free of infectious disease or internal or external parasites (i.e., free

of any infectious disease or physical abnormality which would endanger the dog or other animals or endanger public health).

I certify that all information provided on this form is true and accurate.

VETERINARIAN'S SIGNATURE: PRINTED NAME:

ADDRESS OF VETERINARIAN: COUNTRY:

LICENSE NUMBER OF THE VETERINARIAN ISSUING THE CERTIFICATE: DATE:

THIS SPACE RESERVED

APHIS FORM 7041

NOV 2021
Privacy Act Notice

Authority: The Animal Welfare Act (AWA), 7 U.S.C. 2131 et seq., and the regulations issued thereunder, 9 CFR parts 1 through 4; and the Horse 

Protection Act (HPA), 15 U.S.C. 1821 et seq., and the regulations issued thereunder, 9 CFR parts 11 and 12. 

Purpose: This system supports APHIS’ administrative activities and enforcement of the AWA and HPA. 

Routine Uses: 

In addition to those disclosures generally permitted under 5 U.S.C. 552a (b) of the Privacy Act, records maintained in the system may be disclosed 

outside USDA as follows: 

(1) APHIS may disclose the name, city, State, license or registration type and/or status, or change of a license or registrant to any person pursuant to 

9 CFR 2.38(c) and 2.127;

(2) APHIS may disclose annual reports submitted to APHIS by licensees and research facilities to any person pursuant to 9 CFR 2.7 and 2.36;

(3) APHIS may disclose inspection reports and other regulatory correspondence issued to licensees and registrants [from the agency] to any attending 

veterinarian in order to carry out duties under the AWA pursuant to 9 CFR 2.33 and 2.40;

(4) APHIS may disclose the name, telephone number and other contact information, location, inspection reports, and regulatory and other 

correspondenceof licensees, registrants, permitees, and applicants for the same, to appropriate Federal, foreign, State, local, Tribal, or other public 

authority agencies or officials, in order to carry out duties under the AWA or State, local, Tribal or other public authority on the same subject pursuant to 

7 U.S.C. 2145(b);

(5) APHIS may disclose inspection reports of licensees and registrants, and permit status, to any pet store or other entity that is required under State, 

local,Tribal, or other public authority to verify a licensee, registrant, or permitee’s compliance with the AWA;

(6) APHIS may disclose information to the National Academies of Sciences, Engineering, and Medicine, and any other research institution engaged or 

approved by the Department, to the extent APHIS deems the disclosure necessary to complete research and/or compile a report in furtherance of the 

Department’s mission;

(7) APHIS may disclose final adjudicatory AWA and HPA decisions or orders by an appropriate authority to any person;

(8) APHIS may disclose to any person the name, city, and State or other information to the extent necessary for proper identification of persons 

(referred to as “Designated Qualified Persons” or “DQPs”) that are or have been qualified to detect and diagnose a horse that is sore or otherwise 

inspect horses for purposes of enforcing the HPA and of horse industry organizations or associations (referred to as “HIOs”) that have currently or have 

had in the past DQP programs certified by the USDA;

(9) APHIS may disclose to any regulated horse owner, HIO, and other entities responsible for licensure or required to verify compliance with the HPA, 

HPA inspection findings and regulatory and other correspondence issued to persons or entities regulated under the HPA;

(10) APHIS may disclose to any person the name, city, and State or other information to the extent necessary for proper identification of any person or 

entity who has been disqualified, suspended, and/or otherwise prohibited from showing or exhibiting any horse, or judging or managing any horse show, 

horse exhibition, horse sale, or horse auction under the HPA and the terms of such action;

(11) APHIS may disclose to any person the name, city, and State or other information to the extent necessary for proper identification of any regulated 

individual or entity whose license or permit has been suspended, revoked, expired, terminated, or denied under the AWA and the terms of such action;

(12) APHIS may disclose to appropriate law enforcement agencies, entities, and persons, whether Federal, foreign, State, local, or Tribal, or other 

public authority responsible for enforcing, investigating, or prosecuting an alleged violation or a violation of law or charged with enforcing, implementing, 

or complying with a statute, rule, regulation, or order issued pursuant thereto, when a record in this system on its face, or in conjunction with other 

records, indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether arising by general statute or 

particular program statute, or by regulation, rule, or court order issued pursuant thereto, if the information disclosed is relevant to any enforcement, 

regulatory, investigative, or prosecutive responsibility of the receiving entity;

(13) APHIS may disclose to the Department of Justice when the agency, or any component thereof, or any employee of the agency in his or her official 

capacity, or any employee of the agency in his or her individual capacity where the Department of Justice has agreed to represent the employee, or the 

United States, in litigation, where the agency determines that litigation is likely to affect the agency or any of its components, is a party to litigation or has 

an interest in such litigation, and the use of such records by the Department of Justice is deemed by the agency to be relevant and necessary to the 

litigation; provided, however, that in each case, the agency determines that disclosure of the records to the Department of Justice is a use of the 

information contained in the records that is compatible with the purpose for which the records were collected;

(14) APHIS may disclose information in this system of records to a court or adjudicative body in administrative, civil, or criminal proceedings when: (a) 

The agency or any component thereof; or (b) any employee of the agency in his or her official capacity; or (c) any employee of the agency in his or her 

individual capacity where the agency has agreed to represent the employee; or (d) the United States Government, is a party to litigation or has an 

interest in such litigation, and by careful review, the agency determines that the records are to be for a purpose that is compatible with the purpose for 

which the agency collected the records;

(15) APHIS may disclose information from this system of records to appropriate agencies, entities, and persons when: (a) USDA suspects or has 

confirmed that there has been a breach of the system of records; (b) USDA has determined that as a result of the suspected or confirmed breach there 

is a risk of harm to individuals, USDA (including its information systems, programs, and operations), the Federal Government, or national security; and 

(c) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with USDA’s efforts to respond to the 

suspected or confirmed compromise and prevent, minimize, or remedy such harm;

(16) APHIS may disclose information from this system of records to another Federal agency or Federal entity, when the USDA determines that 

information from this system of records is reasonably necessary to assist the recipient agency or entity in (a) responding to a suspected or confirmed 

breach or (b) preventing, minimizing, or remedying the risk of harm to individuals, the recipient agency or entity (including its information systems, 

programs, and operations), the Federal Government, or national security, resulting from a suspected or confirmed breach;

(17) APHIS may disclose information in this system of records to USDA contractors and other parties engaged to assist in administering the program, 

analyzing data, developing information management systems, processing Freedom of Information Act requests, and conducting audits. Such contractors 

and other parties will be bound by the nondisclosure provisions of the Privacy Act;

(18) APHIS may disclose information in this system of records to USDA contractors, partner agency employees or contractors, or private industry 

employed to identify patterns, trends, or anomalies indicative of fraud, waste, or abuse;

(19) APHIS may disclose information in this system of records to a Congressional office from the record of an individual in response to any inquiry from 

that Congressional office made at the written request of the individual to whom the record pertains;

(20) APHIS may disclose information in this system of records to the National Archives and Records Administration or to the General Services 

Administration for records management activities conducted under 44 U.S.C. 2904 and 2906; and

(21) APHIS may disclose information in this system of records to the Treasury Department as necessary to carry out any and all functions within their 

jurisdiction, including but not limited to, processing payments, fees, collections, penalties, and offsets.

Disclosure: Furnishing this information is voluntary; however, failure to furnish this information may impede your ability to comply with the requirements 

of the Animal Welfare Act, regulations, and standards.