Backyard Chicken Renewal Permit

Applicant Name

First NameLast Name

Property Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

License Year to be Renewed

Renewal Certification (Please check all that apply):

Since your last license was issued, have any of the following changed? (Property ownership, coop location, run location, screening or fencing, number of chickens, other material changes)

If yes, please explain:

Preferred Inspection Date (the Town will conduct an inspection of the property before approving this renewal)

Date

APPLICANT CERTIFICATION

I certify that the information contained in this renewal application is true and correct. I understand that my Backyard Chicken License must be renewed annually and that failure to comply with the requirements of the Town Code or any conditions of my license may result in denial, suspension, or revocation of my Backyard Chicken License. I understand that if any material changes have occurred since my original application, I may be required to submit a new Backyard Chicken License Application.

Signature

Date