MDA Webforms | Uniform-Methods-for-the-Establishment-and-Maintenance-of-Bovine-Leukosis-Virus-Free-Herds

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Owner Information

Prefix

Last Name *

First Name *

Middle Initial

Suffix

Business Name

Address 1*

Address 2

City*

State*

County

Zip Code *

Ext. -

Primary Phone*

Phone Type Ext.

Alternate Phone 1

Phone Type Ext.

Alternate Phone 2

Phone Type Ext.

Alternate Phone 3

Phone Type Ext.

E-mail Address

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Veterinarian Information

Prefix

Last Name*

Last Name	First Name *		Middle Initial		Suffix

Business Name

Licensure Type*

USDA Accreditation NumberState License Number

USDA State Number

Address 1*

Address 1

Address 2

City*

City

State*

Zip code*

Zip Code - Ext

Primary Phone*

primary phone	Phone Type	Ext.

Phone 1

Alternate Phone 1	Phone Type	Ext.

Phone 2

Alternate Phone 2	Phone Type	Ext.

Phone 3

Alternate Phone 3	Phone Type	Ext.

E-mail Address

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Signature

I Certify that the animals appearing on the current herd test are in compliance with all terms of the individual BLV-Free Herd Plan and the certification requirements.

Legal Name*

Date 03/19/2025

Uniform Methods for the Establishment and Maintenance of Bovine Leukosis Virus-Free Herds