License Request

Date

Full Name: *

First Name Last Name

Address: *

Street Address

Street Address Line 2

City

Zip Code

Phone: *

Area Code Phone Number

Alternative Phone:

Area Code Phone Number

E-mail: *

Is this a NEW License, RENEWAL License or Change in Status? *

New Renewal Change in Status (Pet Deceased, Rehomed, etc)

Current License Number:

Is this a Late/Past Due License Renewal? (Honesty is the best policy.) *

Yes - Add $20 late fee No

License Expiration Date

Date

Pet's Name: *

Breed *

Is your Dog Spayed or Neutered? *

Spayed/Neutered NOT Spayed/Neutered

Specify reason for status change: *

Moved Pet is deceased Pet has been rehomed

Please upload a current signed Rabies Certificate: *

Upload a File

Date of Rabies Vaccination: *

Date

Date Rabies Vaccination Expires: *

Date

Calculation

Your pet is due for an updated Rabies vaccine in 30 days or less. You are not currently eligible to purchase a license at this time. Please contact your veterinary office to schedule to get your pet a Rabies vaccine before you apply for a license.

Thank you!

1 Year Eligibility for Sterilized Dog:

1 Year Spayed/Neutered License Fee $10

1 Year Eligibility for Unaltered Dog:

1 Year Unaltered License Fee $30

1 or 2 Year Eligibility for Sterilized Dog:

1 Year Spayed/Neutered License Fee $10 2 Year Spayed/Neutered License Fee $18

1 or 2 Year Eligibility for Unaltered Dog:

1 Year Unaltered License Fee $30 2 Year Unaltered License Fee $55

1, 2 or 3 Year Eligibility for Sterilized Dog:

1 Year Spayed/Neutered License Fee $10 2 Year Spayed/Neutered License Fee $18 3 Year Spayed/Neutered License Fee $25

1, 2 or 3 Year Eligibility for Unaltered Dog:

1 Year Spayed/Neutered License Fee $30 2 Year Spayed/Neutered License Fee $55 3 Year Spayed/Neutered License Fee $75

License Fee *

Square Processing Fee

API Fee

Total Processing

Processing Fee

TOTAL *

Notes:

Payment *

USD License Fee

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

Licensing Request