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DPARTEMENT DE LA SANT ET DES SERVICES HUMANITAIRES
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En caract res d imprimerie) Form Approved OMB No. 0920-0134 DATE (mm/jj/aaaa) POINT D ENTR E - VILLE NOM DU PROPRI TAIRE PASSEPORT N ADRESSE COMPL TE ET N DE T L PHONE DU PROPRI TAIRE PERMIS DE CONDUIRE N TAT METTEUR ADRESSE O LE OU LES CHIENS SERONT PLAC S EN CONFINEMENT Le ou les chiens ci-apr s (nombre, type, ge et description) : qui sont arriv le (Moyen de transport - Nom du navire, no. de vol de l avion, no. de plaque d immatriculation du v hicul.
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