Declaration of Health Status Form

Please use this form to

This form must be completed IN FULL within 36 hours your horse arrives at Brackenspa Stud.

Horses Name

OWNER / AGENT DETAILS

First Name

Last Name

Passport Number

Microchip Number

DECLARATION

To the best of my belief and as far as I can ascertain: 1. I have checked the identity of the above named horse 2. Neither the above-named horse nor his dam has been infected with Taylorella equigenitalis. 3. During the past 6 months, the above-named horse has not been in contact with any animal suffering from Borneo Disease, Contagious Equine Metritis, Equine Viral Arteritis, almonella Abortus Eqi Dourine and Glanders. 4. The above-namedhorse originates from premises, which, for the past 60 days, have not had any cases of Contagious Equine Metritis or Equine Viral Arteritis. 5. The above-named horse has not, for at least the past 30 days, been in contact with equidae suffering from any contagious disease. 6. The above named HORSE originates from a countries which has been free from African Horse sickness, dourine, vesicular stomatitis and glanders for the two years before the collection for this cosignment.

Signed

Name

Date

To be dated within 36 hours of the horse's admission to Brackenspa Stud

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