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Get NJ VPH-26 2012

|_ _|_ _|_ Age (First 3 Letters) FOR LICENSING AGENCY USE License Number Year 1-Yr. Lic/Vacc. 3-Yr. Lic/Vacc. Date Vaccinated / Month Under 20 Lbs. 20 - 50 Lbs. Over 50 Lbs. Vaccine Serial No.: Veterinarian’s Name / / Day / Year Address Rabies Tag No.: Vaccination Expires Other: Control Number: Signature Change Add / Month VPH-26 Predominant Breed: Size 3 – 12 Months 12 Months or Older _| Zip Code JUL 12 / / Day / Year Distribution: Original to Owner Copy to Munic.

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