Dog License Application Form - City Of Alexandria - 2018

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Dog License Application – 2018
(Please use a separate form for each dog)
Date Issued: _______________________
License Fee: $20.00
Name of Owner: __________________________________________________________________________________
Address of Owner: ________________________________________________________________________________
Phone Number: ______________________________
Email: _________________________________________
Name of Person Making Application (if not Owner): _____________________________________________________
Address of Person Making Application (if not Owner): ___________________________________________________
Phone Number: ______________________________
Email: _________________________________________
Breed of Dog: _________________________________________ Description: ______________________________
Gender of Dog: (F) ___ (M) ___ (N) ___ (S) ____
Age of Dog: ______________
Name of Dog: _________________________________________
Signature of Applicant: ____________________________________________________________________________
Please provide required certification of current rabies vaccination (vaccination date not more than two years before the
expiration of this license).
………………………………………………………………………………………………………………………………………………………………………………………….
For City Use:
Fee Received: ____________________
Tag # _____________
Expiration Date: ________________
Date of Rabies Shot: _______________
Veterinary Clinic: ________________________________________

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