Dd Form 2621 - Veterinary Vaccination And Trilingual Health Certificate
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2VETERINARY VACCINATION AND TRILINGUAL HEALTH CERTIFICATE
CERTIFICAT DE VACCINATION VETERINAIRE ET DE SANTE
TIERAERZLICHE IMPFUNGS - UND GESUNDHEITBESCHEINIGUNG
PRIVACY ACT STATEMENT
AUTHORITY:
Title 10, United States Code, Sections 3013, 5013, and 8013.
PRINCIPAL PURPOSE(S):
The personal information will facilitate and document your animal's registration and health care.
ROUTINE USE(S):
Used by veterinarians and other health authorities to request and record the ownership, identity, and vaccination
status of the described animal and to provide verification of normal physical health. The information may also
be used to: aid in preventive health and communicable disease control programs; report medical conditions
required by law to Federal, state, and local agencies; compile statistical data; conduct research; teach; assist in
law enforcement, to include investigations and litigation; and evaluate the care provided.
DISCLOSURE:
Voluntary; however, if the requested information is not furnished, the animal cannot be maintained on the
military installation and comprehensive health care may not be possible.
1. OWNER OF ANIMAL/PROPRIETAIRE DE L'ANIMAL/BESITZER DES TIERES
a. NAME (Last, First, Middle Initial)/NOM (Nom de famille,
b. GRADE/GRADE/RANG
c. SSN/IDENTIFICATION/NUMERO
prenoms)/NAME (Nachname, Vorname)
MATRICULE/IDENTITE/KENNZEICHEN
d. ORGANIZATION/SERVICE/DIENSTSTELLE
e. ADDRESS (Street, City, State, Zip Code)/ADRESSE/ANSCHRIFT
f. TELEPHONE NUMBER (Include Area Code)/NO. DE TEL./TEL. NR.
2. IDENTIFICATION OF ANIMAL/DESCRIPTION DE L'ANIMAL/BESCREIBUNG DES TIERS
a. SPECIES/ESPECE/ART
b. BREED/RACE/RASSE
c. AGE/AGE/
d. SEX/SEXE/
e. WEIGHT/POIDS/
ALTER
GESCHLECHT
GEWICHT
f. NAME/NOM/NAME
g. COLOR/COULEUR/
h. BRAND NO./NO. DE
i. OTHER INFORMATION/RENSEIGNEMENTS
MARQUE/BRANDZEICHEN
FARBE
COMPLEMENTAIRES/WEITERE ANGABEN
NR.
3. RABIES, DISTEMPER, AND OTHER IMMUNIZATIONS (Continued on back)/VACCINATION CONTRE LA RAGE, MALADIE DES CHIENS ET
AUTRES IMMUNISATIONS/TOLLWUT, STAUPE, UND ANDERE IMPFUNGEN
TYPE OF VACCINE OR SERUM
VACCINATION TAG NO.
DATE
LOT NO.
AMOUNT
MANUFACTURER
SIGNATURE
TYPE DU VACCIN OR SERUM
NO. DE LA PLAQUE DE
DATE
NO. DU LOT
QUANTITE
FABRICANT
SIGNATURE
ART DER IMPFUNG ODER DES
VACCINATION
DATUM
REG NR.
MENGE
HERSTELLER
UNTERSCHRIFT
SERUMS
IMPFUNGSSCHILD NR.
b.
c.
d.
f.
g.
a.
e.
4. HEALTH CERTIFICATION/ATTESTATION DE SANTE/GESUNDHEITBESCHEINIGUNG
ABOVE DESCRIBED ANIMAL WAS PHYSICALLY EXAMINED ON DATE BELOW AND FOUND APPARENTLY FREE FROM ALL EVIDENCE OF
INFECTIONS OR CONTAGIOUS DISEASE INCLUDING SKIN LESIONS, DIARRHEA, EMACIATION, AND SYMPTOMS INVOLVING THE
NERVOUS SYSTEM AS NOTED BELOW:
L'ANIMAL DECRIT CI-DESSOUS A ETE EXAMINE PHYSIQUEMENT A LA DATE-DESSOUS ET PARAIT ETRE SANS AUCUN SIGNE
D'INFECTIONS OU DE MALADIES CONTAGIEUSES, Y COMPRIS LESIONS DE LA PEAU, JAUNISSE, DIARRHEE, AMAIGRISSEMENT ET
SYMPTOMES AFFECTANT LE SYSTEME NERVEUX A L'EXCEPTION DE CE QUI EST INDIQUE CI-DESSOUS:
DAS OBEN BESCHREIBENE TIER WURDE AN DEM UNTEN BEZEICHNETEN DATUM UNTERSUCH UN DEM ANSCHEIN NACH WURDEN
EINE ANSTECKENDEN KRANKHEITEN WIE HAUTKRANKHEITEN, GELBSUCHT, DURCHFALL, ABMAGERUNG, UND SYMPTOME IN
VERBINDUNG MIT DEM NERVENSYSTEM FESTGESTLLT, AUSGENOMMEN DER IN DER SPALTE "VERMERK" GEMACHTEN ANGABEN:
a. REMARKS (Continue on back)/REMARQUES/VERMERK
THIS IS TO CERTIFY THAT THE ABOVE STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
IL EST CERTIFIE QUE LES DECLARATIONS CI-DESSUS SONT EXACTES POUR AUTANT QUE JE PUISSE LE SAVOIR.
ES WIRD HIERMIT BESTAETIGT, DASS DIE OBEN GEMACHTEN ANGABEN MEINES WISSENS RICHTIG SIND.
b. TYPED NAME/NOM ECRIT DE MACHINE/
c. GRADE/GRADE/
d. SIGNATURE/SIGNATURE/UNTERSCHRIFT
e. DATE/DATE/
NAME (Mit Schreibmaschine geschreiben)
RANG
DATUM
f. OFFICIAL DESIGNATION/DESIGNATION OFFICIELLE/AMTLICHE BEZEICHNUNG
DD Form 2621, JUN 92
Adobe Professional 8.0
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