Name and address of the licence holder.

Address of premises where the young cat or young dog has been kept (if different from 1 above).

Name of the licensing authority and the animal dealing licence number.

Sex and breed of the animal.

Date of birth of the animal.

Identification number assigned to the animal.

Date the animal was acquired by the licence holder.

Name and address of the veterinary surgeon who conducted a physical examination of the animal in accordance with the animal dealing licence condition under regulation 8(3)(c)(i), and the date on which that examination was carried out.

Details of all medicines administered to the animal prior to sale by, or on behalf of, the licence holder.

Date of sale of the animal by the licence holder.

Date of physical transfer of animal from the licence holder to the purchaser (if different from 10. above).

Name and address of the person to whom the animal is sold by the licence holder.

A statement as to the requirements of regulation 15 (separation of young cats and young dogs).