Johnsburg Town Hall | 219 Main Street | North Creek, NY 12853
(518) 251-2421

DOG LICENSE APPLICATION

TOWN OF JOHNSBURG 219 MAIN STREET NORTH CREEK, NY 12853 518-251-2421 EXT 24

DOG LICENSE APPLICATION

NAME OF OWNER: ___________________________ TELEPHONE #:_______________________

RESIDENCE ADDRESS:____________________________________________________________________________

MAILING ADDRESS:_______________________________________________________________________

E-MAIL ADDRESS:______________________________ Dog’s Name: ___________________________

Dog’s Breed: _____________________________________________ Year of Birth: __________ Color of Dog: __________________

Markings: _________________ ID (Chip#) _________________________ Rabies Vaccination Date:______________________

Veterinarian:_____________________________________________ Vaccine Manufacturer:______________________

Serial No: ______________________ Tag No: _______________________ Please Check ______ One Year _______ Three Years

Type of License Fee (Please check One) MALE, Neutered $5.00 _______ MALE, unneutered, 4 Mos & over $15.00 _____ FEMALE, Spayed $5.00 ______ FEMALE, unneutered, 4 Mos & over $15.00 _____

Owner’s Signature (18 years & over) _______________________________________________

PLEASE SEND A COPY OF RABIES CERTIFICATE ALONG WITH THIS FORM AND PAYMENT OWNER’S INSTRUCTIONS:

1) All dogs four (4) months of age or older are to be licensed, as well as any dog under four (4) months of age if running at large.

2) Print all information, sign and date the form.

3) ID and/or Markings – please indicate implanted electronic chips or tattoos, missing ears, or other significant markings.

4) Check the Type of License for which you are applying. Submit appropriate payment by check or money order made payable to: Town of Johnsburg

5) For validation of this license, submit in person or by mail the application, fee, veterinarian’s certification of spaying or neutering, and proof or rabies vaccination to the Town of Johnsburg Town Clerk’s office.

6) You should receive your next year’s license renewal by mail from the Town Clerk’s office thirty (30) days prior to the expiration date of this license. If a renewal is not received, contact Jo A Smith, Town Clerk at (518) 251-2421 ext 24.