| DOG
LICENSE APPLICATION |
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MALE OR FEMALE |
$9.00 |
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NEUTERED OR SPAYED |
$4.00 |
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| OWNER: |
___________________________ |
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| ADDRESS: |
___________________________ |
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___________________________ |
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| TELEPHONE #: |
___________________________ |
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| SEX: (CIRCLE 1) |
DOG #1 |
DOG #2 |
DOG #3 |
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NEUTERED MALE |
NEUTERED MALE |
NEUTERED MALE |
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SPAYED FEMALE |
SPAYED FEMALE |
SPAYED FEMALE |
| FEE (CIRCLE 1) |
$4.00
$9.00 |
$4.00
$9.00 |
$4.00
$9.00 |
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| DOGS NAME |
______________________ |
______________________ |
__________________ |
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| COLOR |
______________________ |
______________________ |
__________________ |
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| BREED |
______________________ |
______________________ |
__________________ |
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| RABIES(DATE OF SHOT) |
______________________ |
______________________ |
__________________ |
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| EXPIRATION DATE |
______________________ |
______________________ |
__________________ |
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| RABIES TAG# |
______________________ |
______________________ |
__________________ |
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TOTALS $ |
__________________ |
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| I CERTIFY THAT
THE ABOVE DOG(S) RECEIVED THEIR RABIES VACCINATION. |
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| _______________________ |
YOUR SIGNATURE |
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| MAKE CHECK PAYABLE TO: |
TOWN OF WAYNE |
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| MAIL APPLICATION AND |
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| CHECK TO: |
GERALD SCHULZ |
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5520 HWY D |
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WEST BEND, WI 53090 |
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