Spay/Neuter Sterilization Certification Form
Original Invoice from Vet must accompany this form.

Canine D.O.B._____________________(not Age)
Procedure date: __________________                     Male____  or Female_____
Breed:   Golden Retriever ______ or Goldendoodle ______

Client  Name:  ___________________________________________________________________________
           Address:___________________________________________________________________________
           State:____________________________     Zip Code: ________________________
            Phone number:_____________________________________________

I , ________________________________________have surgically altered the 
                                  (Veterinarians Printed name)
above descibed canine to be permanently incapable of procreation.
Veterinarian's Business Name _________________________________________________
Address: ______________________________________________________
 State: _______________________________Zip Code: ________________________
                         Phone Number: _____________________________________________

Veterinarian's Signature: __________________________________________________
                                                                                        (No Stamp will be accepted!)

(Note: Please Mail completed form within 30 days of procedure date to Northland Goldens to qualify for Refund)
Refund will be mailed to the address on this form.
NORTHLAND GOLDENS
2226 W. M 48
Pickford, MI 49774
906-647-6525