****** CLINIC
         TELEPHONE : xxx-xxx-xxxx

         Name           : xxxxxxxxxxxxxx  ( M　F )
         Date of Birth  : MM/DD/YY
         Address        : xxxxxxxxxxxxxxxxxxxxxxxxxxx

         I hereby certify that the immunization record of the above person 

    was officially registed.
                                 

　　　　　　　　　　　　　　　　　　　　　　　　　　　     　（署名）
                                                  Dr. xxxxxxxxxxxxx            
                                                       ******CLINIC