Form Adleb 14-18 - Dog License Application
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1ADLEB 14-18 rev. 9/2014
PA Department of Agriculture, Bureau of Dog Law Enforcement
DOG LICENSE APPLICATION
Year of license
License #
DATE
DOG’S NAME
DOG’S AGE
BREED
COLOR
SPOTTED
WHITE
BLACK
BROWN
OTHER-INDICATE
OF DOG:
If the license is issued by an agent rather than the COUNTY TREASURER, an additional 50¢ will be charged.
ALL PRICES INCLUDE SERVICE FEES ALLOWED BY LAW.
REGULAR FEE
PERSON WITH DISABILITY OR SENIOR CITIZEN FEE
NEUTERED
SPAYED
NEUTERED
SPAYED
MALE
FEMALE
MALE
FEMALE
MALE
FEMALE
MALE
FEMALE
$8.50
$6.50
$8.50
$6.50
$6.50
$4.50
$6.50
$4.50
PLEASE NOTE: IF YOU ARE APPLYING FOR A LICENSE THAT REQUIRES THE DOG OWNER BE
A SENIOR CITIZEN, AGE 65 OR OLDER, OR A PERSON WITH DISABILITY, YOU MUST PROVIDE
PROOF OF AGE OR DISABILITY TO THE COUNTY TREASURER OR AGENT.
OWNER’S NAME
TELEPHONE NO.
OWNER’S DATE OF BIRTH
MO.
DAY
YR.
STREET
TOWNSHIP/BOROUGH
CITY
STATE
ZIP CODE
PA
E-MAIL ADDRESS
I HEREBY VERIFY THAT I AM THE OWNER OF THE DOG THAT IS THE SUBJECT OF THIS DOG LICENSE
APPLICATION. I MAKE THIS STATEMENT SUBJECT TO THE CRIMINAL PENALTIES OF 18 Pa § SECTION 4904
(RELATING TO UNSWORN FALSIFICATION TO AUTHORITIES).
SIGNATURE OF DOG OWNER/APPLICANT REQUIRED
IF APPLICANT IS A MINOR, SIGNATURE OF PARENT OR GUARDIAN IS REQUIRED
MAIL TO COUNTY TREASURER’S OFFICE
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