Donna Lent, Town Clerk
Patricia Ryan, Chief Deputy Town Clerk
Dog License Application rev. 9/19 One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
LICENSE TYPE
PLEASE SELECT ONE: NEW RENEWAL OWNER TRANSFER* REPLACEMENT TAG
Please make check or money order payable to “Donna Lent, Brookhaven Town Clerk” and mail this completed form and
payment to: Town of Brookhaven, Town Clerk, 1 Independence Hill, Farmingville, NY 11738.
New York State law requires all dogs 4 months or older to be licensed and to have their license renewed each year. Dog owners
are req
uired to have a dog license tag attached to the dog’s collar. Dog owners with multiple dogs must license them
individually. License is valid for one year. If applicant is younger than 18 years old, a parent or legal guardian shall be named
the owner of record and the information must be completed by them.
*Applications for ownership transfer must be accompanied by a
written statement from the current owner of record
acknowledging the transfer to the new owner.
LICENSE NUMBER IF RENEWAL,REPLACEMENT, TRANSFER MICROCHIP NUMBER IF APPLICABLE
RABIES
RABIES VACCINATION CERTIFICATE MUST BE SUBMITTED ALONG WITH THIS APPLICATION ACCORDING TO NYS LAW.
CERTIFICATE MUST BE VALID FOR AT LEAST 30 DAYS AFTER OBTAINING A NEW, RENEWAL OR TRANSFER LICENSE. ( A
RABIES TAG IS NOT SUFFICIENT PROOF) A DOG LICENSE WILL NOT BE ISSUED WITHOUT A RABIES VACCINATION CERTIFICATE.
SUBMIT PHOTOCOPY ONLY.
SPAY
NEUTER
APPLICANTS WHO APPLY FOR A NEW OR TRANSFERRED SPAYED/NEUTERED LICENSE MUST SUBMIT PROOF FROM
YOUR VETERINARIAN. SUBMIT PHOTOCOPY ONLY.
BROOKHAVEN LICENSE FEE
FEE
SCHEDULE
SPAYED / NEUTERED ( NEW, RENEWAL, TRANSFER ) $ 7.00 Each
FEE IS THE SAME FOR KENNELS AND BREEDERS
NOT SPAYED / NOT NEUTERED (INTACT) ( NEW, RENEWAL, TRANSFER ) $ 15.50 Each
FEE IS THE SAME FOR KENNELS AND BREEDERS
REPLACEMENT DOG TAG ( A NEW LICENSE NUMBER WILL BE ISSUED ) $ 5.00 Each
SERVICE DOGS INCLUDING POLICE, WAR, GUIDE OR HEARING DOG (PROOF MUST BE SUBMITTED) NO FEE
TOTAL AMOUNT ENCLOSED $
DOG
INFORMATION
NAME OF DOG SEX
BIRTH MONTH/YEAR TOTAL DOGS IN HOUSE
BREED COLORS OF DOG
DOMINANT SECONDARY
SPECIAL MARKINGS
Example: A Dalmatian would be:
Dominant Color: White Secondary Color: Black
SPAYED/NEUTERED IS DOG VACCINATED AGAINST RABIES? DATE OF MOST RECENT VACCINATION & VET NAME
WAS THE DOG EVER DECLARED DANGEROUS OR VICIOUS?
IF A DOG IS DECLARED DANGEROUS OR VICIOUS, THE
OWNER MUST REGISTER THE DOG ON THE DANGEROUS
DOG REGISTRY.
OWNER INFORMATION
OWNER LAST NAME FIRST NAME INT
HOME ADDRESS APT # CITY STATE ZIP CODE
TELEPHONE EMAIL
( )
SIGNATURE OF OWNER DATE
