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.