I am the SELLER and PRESENT OWNER of the horse named below.

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Last Vaccine Dates:

Seller's authorization for an AGENT to act on the SELLER'S behalf

I hereby grant (name below) to act as my Agent regarding all aspects of the Pre-Purchase Examination of the horse named on this form .

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Line

Horses Registered Name

Barn Name

Age

Breed

Sex (please select)

Tattoo (if applicable)

Present Use

Duration of ownership/custody

Current Competition Level and last

Last Vaccination Dates:

Eastern/Western Encephalitis

YYYY

Tetanus

YYYY

Rhinopneumonitis/Influenza

YYYY

West Nile Virus

YYYY

Potomac Horse Fever

YYYY

Rabies

YYYY

Strangles

YYYY

Botulism

YYYY

Last De-Worming (Date and Product)

Has Insurance Coverage ever been denied:

If denied, reason for denial:

Behavior Problems or Concerns:

If so, please describe:

Medical Episodes:

If so, please describe:

Surgical Episodes:

If so, please describe:

Lameness Episodes:

If so, please describe:

HYPP Certification (If applicable):

Reproductive History:

History of Infertility:

Corrective Shoeing:

If yes for corrective shoeing, please describe:

Current Diet:

Supplements:

Medications used to assist performance (Include Adequan, Legend etc):

Is the horse possibly under the effects of any medication at this time?

If yes, please specify:

Veterinarian of Record (with contact information):

Farrier of Record (with contact information):

I hereby authorize Dr. NUSBAUM, DVM, Dr. Loomer, DVM or Dr. Sams, DVM to perform a Pre‐Purchase Examination of the horse named on this document. I understand and agree that:

The Pre‐Purchase Examination will include physical examination; it may also include diagnostic and ancillary services recommended by Dr. Nusbaum, Dr. Loomer, or Dr. Sams and approved by the prospective buyer or designated agent of the prospective buyer.

I consent to the release of all medical records pertaining to the horse named on this document to the prospective buyer and PenMar Equine; such records include those records available from any veterinarians and farriers of record.

If I (or my agent) arrange for someone to ride, drive, an/or handle the horse named on this document for the exam, I understand that person must be 18 years of age or older and accepts the risk of such activity at their own discretion.

I hereby release PenMar Equine and any principals of PenMar Equine from any consequence of the Pre‐Purchase examination to any humans, animals or property.

I am 18 years of age or older and have the authority to execute this document. To the best of my knowledge, the information I provided on this document is true.

First Name

Last Name

Date

YYYY

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