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೎⸥᭽ᑼ╙䋷ภ

⁅›∛੍㒐ᴺ෸䈶ኅ⇓વᨴ∛੍㒐ᴺ䈮ၮ䈨䈒›䈱ャ౉ᬌᩏ↳⺧ᦠ
㪘㪧㪧㪣㪠㪚㪘㪫㪠㪦㪥㩷㪝㪦㪩㩷㪠㪤㪧㪦㪩㪫㩷㪠㪥㪪㪧㪜㪚㪫㪠㪦㪥㩷㪦㪝㩷㪛㪦㪞㪪
㪬㪥㪛㪜㪩㩷㪫㪟㪜㩷㪩㪘㪙㪠㪜㪪㩷㪧㪩㪜㪭㪜㪥㪫㪠㪦㪥㩷㪣㪘㪮㩷㪘㪥㪛㩷㪫㪟㪜㩷㪛㪦㪤㪜㪪㪫㪠㪚㩷㪘㪥㪠㪤㪘㪣㩷㪠㪥㪝㪜㪚㪫㪠㪦㪬㪪㩷㪛㪠㪪㪜㪘㪪㪜㪪㩷㪚㪦㪥㪫㪩㪦㪣㩷㪣㪘㪮
ᐕ䇭䇭䇭䇭᦬䇭䇭䇭䇭ᣣ ↳⺧⠪૑ᚲ᳁ฬ෸䈶ㅪ⛊వ
Year䇭䇭Month䇭 Day Name and address of applicant
᳁ฬ䇭Name
䋨 䋩䇭䇭䇭ශ
૑ᚲ䇭Address
㔚⹤⇟ภ Telephone

േ‛ᬌ∉ᚲ㐳䇭Ლ
To the chief of Animal Quarantine Service
䇭ਅ⸥䈱േ‛䈱ャ౉ᬌᩏ䉕↳⺧䈇䈢䈚䉁䈜䇯
䇭䇭I hereby apply for the import quarantine inspection of the undermentioned animal(s).

ዯ಴ฃℂ⇟ภ
Text
Approval No.

േ‛䈱⒳㘃 㗡ᢙ
Species of animal(s) Quantity

ฬ⒓
Name of animal(s)

୘૕⼂೎ᣇᴺ䋨䊙䉟䉪䊨䉼䉾䊒╬䋩 ୘૕⼂೎⇟ภ/䊙䊷䉪
Means for identification (e.g.microchip) Identification number/Mark

ᮡ⼂ᐕ᦬ᣣ ᮡ⼂ㇱ૏ 㩷䊙䉟䉪䊨䉼䉾䊒䋨䊥䊷䉻䊷䋩䈱⒳㘃


Date of identification(year/month/day) Location of identification Type of microchip (reader)

૕㐳 ૕㜞 ૕㊀
Length 䌣䌭䇭 Height 䌣䌭䇭 Weight 䌫䌧䇭

ຠ⒳ Ძ⦡
Breed Color

ᕈ೎ ↪ㅜ
Sex Use

↢ᐕ᦬ᣣ䋨ᐕ㦂䋩 ઀಴࿖ฬ
Date of birth (Age) Country of export

៞タᐕ᦬ᣣ෸䈶៞タ࿾ ៞タ⦁⥾ 䋨⥶ⓨᯏ䋩 ฬ


Date and place of embarkation Name of vessel (or flight No.)

೔⌕ᐕ᦬ᣣ෸䈶೔⌕᷼
Date and place of arrival

⩄ㅍੱ૑ᚲ᳁ฬ
Name and address of consignor

⩄ฃੱ૑ᚲ᳁ฬ
Name and address of consignee

઀಴࿾䋨㘺㙃ᣉ⸳ฬ⒓෸䈶૑ᚲ䋩
Name and address of the facility in which the animal(s) was/were kept

઀ะ࿾䋨ฬ⒓෸䈶૑ᚲ䋩
Name and address of destination

ㆊ෰䋱ᐕએౝ䈱⸰໧࿖෸䈶䈠䈱ᐕ᦬ᣣ
Countries visited in the past 12 months and the date of visits

⸥౉ᵈᗧ䇭᳁ฬ䉕⥄⟑䈜䉎႐ว䈮䈍䈇䈩䈲䇮᛼ශ䉕⋭⇛䈜䉎䈖䈫䈏䈪䈐䉎䇯


⁅›∛੍㒐ធ⒳ ធ⒳ᐕ᦬ᣣ ᦭ലᦼ㒢 ੍㒐ᶧ䈱⒳㘃 ੍㒐ᶧ䈱⵾ຠฬ෸䈶⵾ㅧળ␠
Rabies vaccination Date of vaccination Date of expiry Kind of vaccine Name of product and manufacturer
(year/month/day) (year/month/day)

ណⴊ೨
Before blood sampling

ណⴊᓟ
㪘㪽㫋㪼㫉㩷㪹㫃㫆㫆㪻㩷㫊㪸㫄㫇㫃㫀㫅㪾

ⴊᶧណขᐕ᦬ᣣ ᛫૕ଔ
Date of blood sampling (year/month/day) Antibody titer IU/ml
⁅›∛᛫૕ᬌᩏ
Rabies serological test
ᬌᩏᯏ㑐ฬ෸䈶૑ᚲ
Name and address of the designated laboratory

ធ⒳ᐕ᦬ᣣ ᦭ലᦼ㒢 ੍㒐ᶧ䈱⒳㘃 ੍㒐ᶧ䈱⵾ຠฬ෸䈶⵾ㅧળ␠


Date of vaccination Date of expiry Kind of vaccine Name of product and manufacturer
(year/month/day) (year/month/day)

䈠䈱ઁ䈱੍㒐ធ⒳
Other vaccination

஻⠨
Remarks

⸥౉ᵈᗧ䇭᳁ฬ䉕⥄⟑䈜䉎႐ว䈮䈍䈇䈩䈲䇮᛼ශ䉕⋭⇛䈜䉎䈖䈫䈏䈪䈐䉎䇯