Certification of Semen Collection and Freezing

Stud Identification

As owner or agent of the owner of the above mentioned stud dog, I hereby authorize representatives of South Mesa Veterinary Hospital to collect, freeze, and store the semen from said stud dog pursuant to the terms specified in the Collection Contract.
I hereby certify that the dog described above was presented for semen collection on the date(s) listed below. At the time of semen collection the dog was clinically examined and found to be free from any signs of disease, contagious or other. The dog 's rabies vaccination was current at the time of collection, and had two testicles normally developed in the scrotum.

Semen stored at: South Mesa Veterinary Hospital, 3801 South Mason Street, Fort Collins, CO 80525