Dog License Application

License Type: Select the type of license you would like.

Renewal for 2012

New for 2012

Please check here if you would like a permit to use the off-leash use area at Van Valkenburg Park. Cost is $25.

Owner Information: Please provide the following information. The red asterisk (*) indicates a required field.

*	Owner's Name:
*	Street Address:
*	Zip Code:
*	Phone Number:

Dog Information: Please provide the following information about your dog. The red asterisk (*) indicates a required field.

Dog's Name:

Breed:

Sex of Dog:

Male Female

Color:

Rabies Information: Please provide the following information about your dog. The red asterisk (*) indicates a required field.

*	Rabies Tag Number:
*	Exact Vaccination Date:	(mm-dd-yyyy) or (mm/dd/yyyy)
*	Vaccination Expiration:	(mm-dd-yyyy) or (mm/dd/yyyy)

Veterinarian Information: Please provide the following information about your dog. The red asterisk (*) indicates a required field.

*	Clinic:
*	Clinic Street Address:
*	Clinic City:
*	Clinic State:
*	Clinic Zip:
*	Clinic Phone:

I understand that some of the information provided on this form will be public data. Public data is available to anyone who makes a request for such information. My credit card number is not considered public data.