Application For Certificate Of Identification Form printable pdf download

American Dairy Goat Association

Phone (828) 286-3801

P.O. Box 865 · Spindale, NC 28160

Fax (828) 287-0476

Application for

CERTIFICATE OF IDENTIFICATION

NAME:

Name must be limited to 30 letters and spaces. Herd Name may only be used by breeder or with breeder’s consent by signature in the

Breeder section.

1st

Choice ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

2nd

Choice ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

If name(s) above is not available, we will alter unless you check here for return 

COLOR AND MARKINGS:

Limited to 69 letters and spaces.

Be accurate but make

description as short as

possible. Please provide

basic color.

SEX:

BREED OR BREED TYPE:

Buck  Doe 

DATE OF BIRTH:

 Date of Birth Estimated

 Alpine  LaMancha  Nigerian Dwarf  Nubian  Oberhasli

Month ________________ Day _______ Year ________

 Saanen  Sable  Toggenburg  Boer  Pygmy  Unknown

If unknown, please estimate.

NAME AND LOCATION OF PLACE OF ORIGIN:

The known place or facil-

ity at which the goat origi-

nated.

BREEDER:

Name, address, ID# and Signature.

 Not Identified

Name ____________________________________________________________________________________ ID# ________________

Address ____________________________________________________________________________________

Check the “Not Identified”

box if you do not know or

City _____________________________________________________ State ___________ Zip ______________

do not have permission

by signature of breeder.

Breeder’s Signature __________________________________________________________________________

TATTOO:

Registered tattoo of owner signing below is required to be on animal.

Right Ear ___ ___ ___ ___

Right tail web ___ ___ ___ ___

Electronic ID ___________________________________

Left Ear ___ ___ ___ ___

Left tail web

___ ___ ___ ___

Location:

Tail

Base of Ear

Shoulder

Flank



Center tail web ___ ___ ___ ___ ___ ___ ___ ___

Dewclaw

Other ____________________



USDA Scrapie Certification Tag # _________________________________ Left Ear Tag ___________ Right Ear Tag ____________

OWNER SIGNATURE:

I hereby certify to the truth and accuracy of the above data. I offer this goat for consideration of a

certificate of identification through the American Dairy Goat Association.

Print Name ________________________________________________________________________________ ID# ________________

Address ________________________________________________ City ________________________ State _______ Zip ____________

Owner’s Signature Required _______________________________________________________________________________________

This item is used only

TRANSFER: I have on _________________ (M) _________ (D) __________ (Y), sold above described goat to:

when the animal is being

transferred

another

Name of purchaser _________________________________________________ Member ID# ______________

ownership. Do not use

this space unless you

Address ___________________________________________________________________________________

wish to transfer the ani-

mal to a new owner. The

appropriate fee for trans-

City ___________________________________________________ State _________ Zip _________________

fer must be enclosed.

Signature of seller _______________________________________________________ ID # _______________

FEES:

Check, Money Order, Visa,

Total $ ________

$12 - Certificate of ID fee - Member

$ 4 - Transfer fee if Buyer or Seller member

MasterCard & Discover Accepted

$24 - Certificate of ID fee - Nonmember

$16 - Transfer fee if Buyer & Seller nonmembers

Certificate of Identification Fee ....................................................... $ __________

Card # ______________________________________ Exp. _________

Transfer (if Transfer section has been completed) ......................... $ __________

Name on Card _____________________________________________

 Rush Fee Enclosed - 100% of Certificate of Identification Fee ... $ __________

Billing Address _____________________________________________

(Mark RUSH on front of envelope)

Donation (50¢ or more):  History Preservation  Research  Scholarship $ _________ ________________________________________________________________

COI20160210

Application For Certificate Of Identification Form

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