Page 1 of 1

International Travel Confirmation/FedEx Statement

Date:

Court Square Animal Hospital

42-34 Crescent Street, Long Island City, NY 11101

Phone: 718-577-4701

Client Name:

Client Address:

Client Phone #:

Client Email:

Person Traveling with Pet:

Destination Address:

Flight Date:

PET INFORMATION**Ensure Name is As Written on Passport**

I hereby acknowledge that I (or a consignor on my behalf) have reviewed and confirmed the accuracy of the entirety of the information listed above. This information will be used to issue a health certificate to the country listed on the date noted above.

I, understand that the FedEx delivery time is not under the control of Court Square Animal Hospital. I acknowledge that unforeseen circumstances may delay my document or result in it not arriving on time, although I am paying for overnight shipping. I agree to wait until the hospital notifies me that the document has been delivered to their office and is ready for pick up.

International Travel Confirmation/FedEx Statement

Date:

Client Name:

Client Address:

Client Phone #:

Client Email:

Person Traveling with Pet:

Destination Address:

Flight Date:

Signature:

Date:

Staff/Witness Signature

Date: