CEM Quarantine - Stallion This completed form is required by law in order for us to provide service. This information is kept secure, private and will not be shared with any 3rd party without your expressed consent. CEM Stallion Primary Form - Please complete this form if importing one stallion. If importing an additional stallion or mare, you will see a link to a short form for an additional stallion or mare following the completion of this form.Owner's Name* First Last Physical Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mailing Address (if different, otherwise leave blank) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mobile Phone Number*Email* Enter Email Confirm Email Agent Name First Last Agents Company Name Agent Phone NumberAgent Email Preferred Primary Contact: Name* First Last Preferred Primary Phone Number*Preferred Primary Contact Email* Expected or Estimated Landing Date at LAX* MM slash DD slash YYYY Stallion Name* Date of Birth* MM slash DD slash YYYY Breed* Color* Markings* Height* Weight* Microchip Number (Please enter 0000 if not known or absent)*HiddenHorse(s) Imported*Stallion's NameAge (yr/mo) or Date of BirthStallonBreedColorMarkings (head, legs, brand?)HeightWeightMicrochip Number Please list all horses that will be presented for quarantine. Health and Husbandry Information - Please Indicate which statements ARE TRUE.* Influenza vaccine given within 6 months. Rhinopneumonitis vaccine given within 6 months. Tetanus vaccine given given within one year. Grass Hay Preferred. Alfafa Hay Preferred. Alfalfa/Grass Combination Preferred. Grain Supplementation (see later under "Add-Ons") Is Mortality/Major Medical Insurance in place?* Major Medical and Mortality Mortality only No Insurance Additional information or free text instructions - Please list here.Consent - Terms of Care* I agree to terms of care.Pursuant to this agreement, the Owner/Agent authorizes Rogue Equine Hospital (REH) to exercise control and custody of the horse, and requests REH to provide basic CEM quarantine services, arrange for all state-required CEM cultures, procedures and washings to be performed by a state-approved veterinarian, present the horse for inspection to required state agents, and represent the owner’s interest with the applicable state and federal agencies. REH will provide standard CEM quarantine for the horse described herein in accordance with state and federal regulations, including all state veterinarian costs and expenses and all private veterinarian costs and expenses associated with standard CEM protocol. A qualified veterinarian routinely inspects all horses upon arrival. This initial health inspection will initiate the CEM quarantine protocol. Any adverse findings of the horse’s condition will be immediately disclosed to the owner. Mares will be quarantined for approximately 15-20 days, depending on weekends and holidays, and laboratory turnaround time for sample processing. Add-On Service List Additional Hay/Free Fed REH-CEM Provided Grain as directed REH-CEM Provided Supplements as directed Blanketing Grooming Turn Out - Paddock/Outside Pen Hand Walk Lounge Hack Semen Collection and Freezing ** Additional service provided with fee. We will confirm with you the fee before activating/performing the service. Fee Agreement* I agree to fees as stated.Owner agrees to pay a Contract Price of $6982.00 for the quarantine period of one stallion. This fee is due and payable in full before departure. A non-refundable deposit of $3491.00 is due and payable upon acceptance of this signed agreement. CEM Fees include: daily board, hay, water, individual turnout, unsealing of the trailer and initial inspection made by a State or Federal veterinarian upon arrival, as well as all costs associated with USDA mandated CEM quarantine protocols. The Contract Price is for standard CEM quarantine protocol only. Any and all extraneous veterinary work, including but not limited to, an extended quarantine period, additional cultures, sedation (if the attending veterinarian deems it necessary for staff or patient safety) or emergency services are not included in the contract price and will be itemized and billed to the Owner. Any Additional Services will be itemized and charged, and will be billed in addition to the above costs for quarantine. In the event that a stallion tests positive for CEM, the Owner agrees to pay for the replacement of two test-mares. This requires young to middle-aged, well-handled, serviceably sound, grade-bred horse mares. The total expense could be up to but not exceed $5,000.00. Signer agrees that any dispute regarding non-payment of non-refundable deposit or any other due fee will be resolved in Jackson County, Oregon and will be responsible for both party attorney fees and court cost. Release of Liability* I agree to release Rogue Equine Hospital from liability as stated belowThe Owner hereby agrees to release and to hold harmless Rogue Equine Hospital, their agents, employees, officers, directors, owners, and representatives against any and all liabilities, claims, damages, actions, suits or causes of action arising out of or associated with any injury, loss, death or property damage sustained by Owner, its principals, owners, directors, agents, officers, employees, representatives or any third parties, including but not limited to veterinarians, farriers, equine professionals, guests or invitees on the premises at the direction or request of Owner. The owner acknowledges and understands that it is the owner’s sole responsibility to insure the horse for injury or death, and the owner further acknowledges that REH is not responsible for insuring the horse in any capacity. Indemnification* I agree to indemnify Rogue Equine Hospital.The Owner hereby agrees to indemnify and to hold harmless Rogue Equine Hospital against any and all liabilities, claims, damages, losses, and expenses which Owner may incur or be required to pay should any claim be brought by a third party as a result of any act, intentional or negligent, or omission on part of the Owner in connection with the use and enjoyment of this facility under the terms of this agreement. Owner agrees to defend Rogue Equine Hospital in any action, suit or proceeding brought by any other party based upon or related to any activities involving the horse herein described while horse was in the custody and under the care of Rogue Equine Hospital, or involving a party who has sustained damage to property caused by horse while horse was in the custody and under the care of Rogue Equine Hospital, whether or not such injury or damage was sustained through no negligence of Rogue Equine Hospital, its employees, agents, owners, or directors. It is hereby agreed that Owner must be given notice of a claim relating to any action relating to horse and the terms of this agreement in a timely manner. Visitation Policy* I agree to Rogue Equine CEM visitation policy.All visitors of quarantined horses must comply with the regulations of the Rogue Equine Quarantine Facility and the restrictions in place due to the CEM Quarantine protocol. For the safety and respect of all owners and horses in the facility, visitors must be accompanied by authorized personnel. Visiting hours are Monday – Friday, 9am-5pm, and by appointment only. Duration may be limited to availability of authorized personnel. A deposit for 50% of the contract price is due prior to the horse’s arrival at the CEM quarantine facility. For stallions this value is $3491.00 Payment for the remainder of the contract price, and costs for any additional services provided is due BEFORE the horse is released from quarantine. All balances must be paid in full prior to the horse’s departure. The preferred payment method is Direct Wire Transfer. Wire transfer instructions will be forwarded upon return of this form. We do accept Credit Cards as method of payment and can alternatively send you a credit card authorization form. Please note a 3% transaction fee will be applied to credit card payments. Please indicate your choice below* I will pay by Wire Transfer I will pay by Credit Card Signature*Date* DD slash MM slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
