Rev. 4/28/2020
Fee: $___________
Owner Information:
Name: ________________________________________________________________
Address: ______________________________________________________________
Telephone Number: _____________________________________________________
Pet Information:
Name: ________________________________________________________________
Color: _______________________ Breed: _____________________________
Sex: ______________________ Spayed/Neutered: ___________________
Rabies Vaccination Date: _____________ Rabies Expiration Date:________________
Vaccine Manufacturer: _______________ Vaccine Serial Number: _______________
Attach the following:
______ Liability insurance policy written by an insurance company licensed
to do business in the State of Wisconsin, covering death and
personal injury, in the amount of at least $300,000.00 and property
damage in the amount of at least $50,000.00. The policy shall
provide notice to the city clerk 30 days in advance of any material
change therein or of its termination or non-renewal.
______ Current vaccination information for rabies.
______ Current dog/cat license.
______ Proof of spayed/neutered.
I certify that all the information provided on this form is true and correct.
__________________________________ __________________________
Signature Date
Email Address: ___________________________________________________
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