Dear Adopter and Veterinarian:

Please complete this form and return it to the charity office at ASAP Inc., S 6039 Pedretti Lane, De Soto, WI 54624 no later that June 15th. Any questions may be directed to our office at (608) 689-2399. Your cooperation is deeply appreciated.

Circle One: (Spring) (Fall) Year:______________

Horse Name: _________________________________________________

Age: _____________________

Color: ___________________

Markings: _________________________________________________________

Immunization Date: _____________________________

Immunizations administered: _____________________________________________________________________

Were these shots administered by VETERINARIAN or ADOPTER (circle one)

Last worming date: __________________ Type of Wormer: ____________________________________________

Teeth floated: YES - NO

Last date of floating: ________________________________

Veterinarian: Please describe the overall condition of the horse (comment on fleshiness, condition of teeth and hooves and overall soundness):

____________________________________________________________________________________________

____________________________________________________________________________________________

Adopter comments: _____________________________________________________________________________

____________________________________________________________________________________________

Veterinarian name and address: ____________________________________________________________________

____________________________________________________________________________________________

Veterinarian signature: _______________________________________ Date: _______________________________

Veterinarian Phone Number: ______________________________________

Adopter Signature: _________________________________________ Date: _______________________________

Is the above veterinarian the adopter's regular practicing vet? (circle one) YES - NO

If no, who is your usual veterinarian who is most familiar with the above mentioned horse?

___________________________________________________________________

Where may they be reached? _________________________________________________________________

Thank you for your time!