Form 402-3028 - Wsda Order For Supplies
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1CASHIER USE ONLY
State Veterinarian's Office
PO Box 42591
Olympia WA 98504-2591
(360) 902-7566 • FAX (360) 902-2087
WSDA ORDER FOR SUPPLIES
5105
Ordering Accredited Veterinarian: ______________________________________________________________________
Name of Clinic: ____________________________________________________________________________________
U.P.S. Address: ____________________________________________________________________________________
City: _______________________________________________________State:___________Zip: ___________________
Telephone Number: _________________________________________________________________________________
Credit card orders may be sent via fax. If paying by check, you must call for a shipping quote. Payment must be received
prior to order being processed. Please make checks payable to: WSDA. Allow 2–3 weeks for delivery.
ITEM
DESCRIPTION OF ITEM
QUANTITY/UNIT
UNITS ORDERED
UNIT COST
TOTAL
Federal Forms
VS 4-26
Brucellosis Vaccination Record
100/Pkg.
Pkg.
N/C
N/C
VS 4-33
Brucellosis Test Record
50/Pkg.
Pkg.
N/C
N/C
VS 4-33A
Brucellosis Test Record Continuation
50/Pkg.
Pkg.
N/C
N/C
Tuberculosis Test Record
VS 6-22
50/Pkg.
Pkg.
N/C
N/C
Must be WSDA Bovine TB Certified to order
VS 6-22B
Tuberculosis Test Record Continuation
50/Pkg.
Pkg.
N/C
N/C
VS 10-11
Equine Infectious Anemia (EIA) Test Record
50/Pkg.
Pkg.
N/C
N/C
Brucellosis Test Record - Market Cattle Testing
VS 4-54
100/Pkg.
Pkg.
N/C
N/C
Saleyard veterinarians ONLY
State Forms
AGR 300-3007
Certificate of Veterinary Inspection (Large Animal)
25/Pad
Pads
$5.00
$
AGR 300-3008
Official Small Animal Health Certificate
50/Pad
Pads
$5.00
$
AGR 300-3026
Horse Passport
25/Pad
Pads
$5.00
$
Ear Tags
Calfhood & Mature Vaccination Button Tag (ORANGE)
20/Bag
Bags
$43.00
$
RFID Brucellosis
Animal Identification Number (AIN) Half Duplex (HDX) Tag
Box
100/Box (or)
Metal Brucellosis Calfhood Vaccination (ORANGE)
N/C
N/C
1,000/Case
Case
Box
100/Box (or)
Metal Brite Tag
Identification Tag (SILVER)
1,000/Case
N/C
N/C
Case
Identification Tag (Color - Year Specific)
Trich Panel Tag
25/Bag
Bags
$25.00
$
Must be WSDA Trich Certified to order
Tag Applicators
Hasco Style 49/56SA Applicator
Metal Tag Applicator
Each
Each
$20.00
$
Aluminum construction - for use with metal tags shown above
Allflex Universal Total Tagger Applicator (RED)
RFID Tag Applicator
Each
Each
$20.00
$
For use with RFID Brucellosis and Trich Panel tags shown above
WSDA STAFF USE ONLY
WSDA Will
Distribution
$14.95
$ 14.95
Cost
(Per Order)
Complete
VALIDATED BY
DATE
Shipping
Actual Cost $
Shipping
Cost Info
Applied
TAG TYPE / SERIES
TOTAL
$
TAG TYPE / SERIES
CREDIT CARD ORDERS ONLY—FILL IN INFORMATION BELOW
CARD TYPE
CARD NUMBER
TAG TYPE / SERIES
MASTERCARD
VISA
SIGNATURE OF CARDHOLDER
EXPIRATION DATE
DATABASE
DATE
INITIALS
UPDATED
Checks returned by the bank will be charged a handling fee of $25.00 (RCW 62A.3.515(a) and 62A.3.520).
AGR FORM 402-3028 (R/10/13)
Previous versions obsolete
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