ADLEB 14-18 rev. 9/2014
PA Department of Agriculture, Bureau of Dog Law Enforcement
DOG LICENSE APPLICATION
Year of license License #
DATE DOG’S NAME DOG’S AGE BREED
COLOR SPOTTED WHITE BLACK BROWN OTHER-INDICATE
OF DOG:
If the license is issued by an agent rather than the COUNTY TREASURER, an additional 50¢ will be charged.
ALL PRICES INCLUDE SERVICE FEES ALLOWED BY LAW.
REGULAR FEE PERSON WITH DISABILITY OR SENIOR CITIZEN FEE
NEUTERED SPAYED
MALE FEMALE
MALE FEMALE
$8.50 $6.50 $8.50 $6.50
NEUTERED SPAYED
MALE FEMALE
MALE FEMALE
$6.50 $4.50 $6.50 $4.50
PLEASE NOTE: IF YOU ARE APPLYING FOR A LICENSE THAT REQUIRES THE DOG OWNER BE
A SENIOR CITIZEN, AGE 65 OR OLDER, OR A PERSON WITH DISABILITY, YOU MUST PROVIDE
PROOF OF AGE OR DISABILITY TO THE COUNTY TREASURER OR AGENT.
OWNER’S NAME TELEPHONE NO. OWNER’S DATE OF BIRTH
MO. DAY YR.
STREET TOWNSHIP/BOROUGH
CITY STATE
PA
ZIP CODE
E-MAIL ADDRESS
I HEREBY VERIFY THAT I AM THE OWNER OF THE DOG THAT IS THE SUBJECT OF THIS DOG LICENSE
APPLICATION. I MAKE THIS STATEMENT SUBJECT TO THE CRIMINAL PENALTIES OF 18 Pa § SECTION 4904
(RELATING TO UNSWORN FALSIFICATION TO AUTHORITIES).
SIGNATURE OF DOG OWNER/APPLICANT REQUIRED
IF APPLICANT IS A MINOR, SIGNATURE OF PARENT OR GUARDIAN IS REQUIRED
MAIL TO COUNTY TREASURER’S OFFICE
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