Form Dl-1 - Dog License - New York State Department Of Agriculture And Markets

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DL-1 Rev. 12/95
DOG IDENTIFICATION
New York State Department of Agriculture and Markets
Division of Animal Industry
License No.
Chk Code
1 Winners Circle - Albany, New York 12235
518-457-2728
RABIES CERTIFICATE REQUIRED
DOG LICENSE
Rabies Vaccine:
Date Issues
Expiration Date
Manufacturer __________________________
Issuing County Code/TCV Code
Dog Breed
Code
Serial Number __________________________
Dog Color(s)
Code(s)
□ □ □ □ One Year Vacc.
□ □ □ □ Three Year Vacc.
LICENSE TYPE
Other ID
Dog’s Yr. of
□ □ □ □
□ □ □ □
Date Vaccinated ______________________
Birth Last 2 Digits
ORIGINAL
RENEWAL
Markings
Dog’s Name
□ □ □ □
Veterinarian ______________________________
TRANSFER OF OWNERSHIP
OWNER’S PHONE NO.
Owner Identification (Person who harbors or keeps dog): Last First Middle Initial
Area Code
Mailing Address: House No. Street or R.D. No. and P.O. Box No.
Phone No.
City
State
Zip
County Code
County
Town, City or Village
Town, City, Vil. Code
TYPE OF LICENSE
State fee Spay/Neuter Fee
STATE FEE______________________
□ Male, neutered
1.
2.50
LOCAL FEE______________________
□ Female, spayed
2.
2.50
3.
Male, unneutered
SPAY/NEUTER FEE_______________
□ under 6 months
7.50
TOTAL FEE______________________
□ 6 mos. & over
7.50
3.00
4.
Female, unspayed
IS OWNER LESS THAN 18 YEARS OF AGE?
YES
NO IF YES, PARENT OR GUARDIAN SHALL BE DEEMED THE
□ under 6 months
OWNER OF RECORD AND THE INFORMATION MUST BE COMPLETED BY THEM.
7.50
□ 6 mos. & over
7.50
3.00
□ Exemption (Guide dog,
5.
NO FEE
war dog, police dog, hearing
___________________________________________________________________________________
dog, service dog)
Owner’s Signature
Date
Clerk’s Signature
Date

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