New Jersey Department of Health

Infectious and Zoonotic Diseases Program

PO Box 369

Trenton, NJ 08625-0369

ANIMAL POPULATION CONTROL PROGRAM

PROXY AUTHORIZATION

This authorization falls under Public Law 1983, Chapter 172 of New Jersey. Any falsification of information on this or related document is punishable by fines under the penalty enforcement law.

Name of Pet Owner (Print)

Telephone No.

Address of Pet Owner

Name of Proxy (Print)

Telephone No.

Address of Proxy

I hereby authorize the above-named proxy to represent me with respect to the following animal(s) which are owned by me:
Description of Animal	Dog	Cat	Age
I am eligible under the following program:

Food Stamps	Rental Assistance

Supplemental Security Income (SSI)	Lifeline Credit

Aid to Families w/Dep. Children (AFDC)	Tenants Lifeline Assistance

General Public Assistance (Welfare)	Medicaid

Pharmaceutical Assistance to the Aged and Disabled	Shelter Adoption
My program identification number is
Signature of Pet Owner	Date
Signature of Proxy	Date
Name of Veterinarian (Print)

Hospital Name

Signature of Veterinarian	Date

APC-11

AUG 12	Distribution: Original to Veterinarian

APC-11, Proxy Authorization

APC-11, proxy authorization, animal population control program, IZDP, infectious and zoonotic diseases,

Elaine White

2012-03-15

ewhite

NJDOH