HTML Preview Printable Official Order Form page number 1.
OFFICIAL ORDER FORM
Please FAX this request to (502) 573-1020, Attn: Shipping
THIS BOX MUST BE FILLED
OUT COMPLETELY
For Official Use Only
Box No. Weight Cost Tracking Number
1
2
Date Shipped: ___________ Initials: _________ KY Premise # (if applicable): _______________
STATE FORMS
Quantity
CEM CF TEST (KYSV-300) 50 per pkg
EVA TEST FORM (KYSV-302) 40 per pkg
CVI-LARGE (KYSV-72) 25 per book
CVI-EQUINE (KYSV-73) 25 per book
CVI-SMALL (KYSV-74) 25 per book
RECONSIGNEE (KYSV-75) 25 per pkg
MULTIPURPOSE TEST RECORD (KYSV-608) 100 per pkg
ORANGE TAGS (Calfhoods) 100 per box – 1,000 per case (specify)
SILVER TAGS (61ABC####) 100 per box – 1,000 per case (specify)
SILVER TAGS (USABC####) 100 per box – 1,000 per case (specify)
SWINE (61AB####) 100 per box – 2,000 per case (specify)
For official use only:
FEDERAL FORMS
Quantity
VS FORM 4-24 BRUCELLOSIS VAC [short] 50 per pkg
VS FORM 4-26 BRUCELLOSIS VAC [long] 100 per pkg
VS FORM 4-33 BRUCELLOSIS TEST 50 per pkg
VS FORM 4-33a CONT SHEET 50 per pkg
VS FORM 6-22 TUBERCULOSIS 50 per pkg
Contact Information (PLEASE PRINT)
P
hone:
____________________
Date:
________________
Veterinarian Name:
________________________________
Clinic Name:
_____________________________________
Address (NO P.O. BOXES):
__________________________
City, State, Zip:
___________________________________
Six-Digit USDA Accreditation #:
_ _ _ _ _ _
Circle Level: 1 / 2
Rev. 11/2016