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

Please DO NOT include any personal, confidential, and/or sensitive information in your responses on this form (e.g. social security number, credit card information, health information, account number, etc.).

Owner Information

Prefix

Last Name *

First Name *

Middle Initial

Suffix

Business Name

Address 1*

Address 2

City*

State*

County

Zip Code *

Ext. -

Primary Phone*

* x

Phone Type * Ext.

Alternate Phone 1

* x

Phone Type * Ext.

Alternate Phone 2

* x

Phone Type * Ext.

Alternate Phone 3

* x

Phone Type * Ext.

E-mail Address

Confirm E-mail Address

Veterinarian Information

Prefix

Last Name*

last name required Last Name	First Name *	first name required	Middle Initial		Suffix	required

Business Name

Licensure Type*

USDA Accreditation Number

State License Number

USDA State Number

Address 1*

Address 1

Address 2

City*

City

State*

Zip code*

Zip Code - Ext

Primary Phone*

phone required phone invalid primary phone	Phone Type type required	Ext.

Phone 1

phone required phone invalid Alternate Phone 1	Phone Type type required	Ext.

Phone 2

phone required phone invalid Alternate Phone 2	Phone Type type required	Ext.

Phone 3

phone required phone invalid Alternate Phone 3	Phone Type type required	Ext.

E-mail Address

Confirm Email Confirm E-mail Address

Confirm E-mail Address

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 04/26/2024

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