015 Dog License Application Form - City Of Jersey City printable pdf download

015 Dog License Application Form - City Of Jersey City

CITY OF JERSEY CITY

DEPARTMENT OF HEALTH & HUMAN SERVICES

H.H.S. | 199 SUMMIT AVENUE| JERSEY CITY, NJ 07304

P: 201 547 6800 | F: 201 547 5168

STEVEN M. FULOP

STACEY L. FLANAGAN

MAYOR OF JERSEY CITY

DIRECTOR

2015 DOG LICENSE APPLICATION

Licenses may be purchased for a period of 12 Months (1 Year) or 36 Months (3 Years).

Please complete the form below and return it with your check/money order made payable to:

JERSEY CITY DIVISION OF HEALTH and mail to:

ANIMAL CONTROL, 199 SUMMIT AVE, JERSEY CITY, NJ 07304

DOG OWNER/GUARDIAN INFORMATION [Please print clearly]

First name:

__________________________

Last name:

_________________________________________

Street address:

_____________________________________________ Apt # _______

Zip code: ____________

Preferred phone:

_____________________________

Alternate phone: _____________________________

Email address:

___________________________________________________________________________________

(We will not share your email address)

DOG INFORMATION [Please print clearly]

Dog’s name:

Dog’s age: _________

______________________________________

Sex:

(circle one)

Breed:

________________________

Spay/ neuter:

YES

Hair: SHORT

MEDIUM

LONG

(proof required)

(circle one)

Color & markings:

____________________________________

Microchip #:

____________________________

All licenses effective May 1, 2015; all fees non-refundable.

1 Year License (expires 4/30/16) -

Rabies shots must be up to date until 3/1/16

Neutered dogs $10

Unneutered dogs $20

3 Year License (expires 4/30/18)

- Rabies shots must be up to date until 3/1/18

Neutered dogs $25

Unneutered dogs $50

Proof of Rabies Vaccination or Exemption Letter

All applications require a copy of the rabies vaccination certificate showing it to be valid through the license period and

attached to the application when filed. Dogs incapable of being inoculated are exempted when certified in writing by a duly

licensed veterinarian (original exemption letter or NJ VPH-28 “CERTIFICATE OF EXEMPTION” form is required).

$5 late fee for licenses not renewed by May 31, 2015. (Does not apply to new applicants.)

015 Dog License Application Form - City Of Jersey City

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