www.agriculture.az.gov
Seasonal Pass Application for Single Livestock
Arizona Department of Agriculture
Animal Services Division – Self-Inspection
1688 W. Adams St.
Phoenix, AZ 85007
(602) 542-6407 selfinspection@azda.gov Fax (602) 542-4290
$5.00 FEE per exhibitor for up to 10 animals. If more than 10 animals, add $0.50 for each additional animal.
Name: _____________________________________________________________________________________________________
(Last) (First) (Middle Initial)
Email Address: _____________________________________________________ Phone Number: __________________________
Physical Address: ____________________________________________________________________________________________
_____________________________________________________________________________________________
(City) (State) (Zip Code)
Mailing Address: ____________________________________________________________________________________________
_____________________________________________________________________________________________
(City) (State) (Zip Code)
Name of Group: _____________________________________________________________________________________________
(4-H, FFA, etc.)
Group Leader’s Name: _______________________________________________________________________________________
Type of Livestock: ☐ Cattle ☐ Sheep ☐ Goat ☐ Swine Premise ID: ____________________________________________
(Please check) REQUIRED for sheep, goats, & swine
Breed: _____________________________________________________________________________________________________
Sex: _______________________________________________________________________________________________________
Color: _____________________________________________________________________________________________________
Permanent I.D. (ear tag, brand, tattoo, microchip, ear notch):__________________________________________________________
REQUIRED for sheep, goats, swine, & most out-of-state cattle
Name of Seller (if purchased in Arizona): _________________________________________________________________________
REQUIRED
Arizona Inspection Certificate Number (if purchased in Arizona): ____________________________________________________
REQUIRED – a Livestock Inspection Form or Self-Inspection Certificate Number
Health Certificate Number: ________________________________ Entry Permit Number: _______________________________
REQUIRED if livestock has been brought in from out-of-state and must be in exhibitor’s name
Owner/Lessee Signature: _______________________________________________________________Date:__________________
MUST SIGN or application will not be processed
Parent/Guardian Signature: _____________________________________________________________Date:_________________
If owner/lessee is under 18 years of age, the parent/guardian MUST SIGN or application will not be processed
(By signing, owner/lessee and/or parent/guardian state that the information provided on this application is true to the best of his/her knowledge.)
Douglas A. Ducey
Governor
Mark W. Killian
Director
