New Jersey Department of Health

Infectious and Zoonotic Diseases Program

P. O. Box 369

Trenton, NJ 08625-0369

CERTIFICATION OF VETERINARY SUPERVISION

OF THE DISEASE CONTROL AND HEALTH CARE PROGRAM

AT A LICENSED ANIMAL FACILITY

N.J.A.C. 8:23A‑1.9(a) requires that this form be updated yearly and posted at the facility in an area clearly visible to the public.

LICENSED ANIMAL FACILITY INFORMATION
Name of Licensed Animal Facility

License Number

Street Address

City, State, Zip Code

CERTIFICATION BY SUPERVISING VETERINARIAN
This is to certify that I have established and am maintaining a disease control and health care program at the above licensed animal facility, as specified in N.J.A.C. 8:23A-1.9(a).
Name of Veterinarian (Print)

License Number

Street Address

City, State, Zip Code

Telephone Number (During Business Hours)

Telephone Number (After-Hours Emergencies)

Signature	Date

- THIS FORM TO BE RETAINED AT FACILITY -

VPH-20

MAY 16

VPH-20, Certificate of Veterinary Supervision

vph-20, veterinary supervision, licensed animal facility, IZDP, zoonotic, rabies control,

ewhite

2002-04-11

njdoh