OFFICE OF THE TOWN CLERK
KATE MURRAY
Town Clerk
One Washington Street Hempstead, NY 11550
Tel: (516) 812-3034
email: licensing@tohmail.org
RABIES CERTIFICATE REQUIRED
One Year Vacc. Three Year Vacc.
Date Vaccinated:
Veterinarian:
Owner’s Signature Date
Town Clerk
Rev. 1/20
RENEWALORIGINAL DECEASED
TRANSFER OF
OWNERSHIP
Dog Tag #
Microchip #
Date Issued
Expiration Date
Dog Breed
Code:
Code:
Sex:
Email Address : __________________________________________
DOG’S NAME
Dog Color/s
Year of Birth
Total Fee $
Apt. # Zip Code
N A S S A U
County
HEMPSTEAD
Town
Owners Last Name Owners First Name
Mailing Address City
Phone Number
--
DOG LICENSE
DONALD X. CLAVIN JR.
Supervisor
DOG’S INFO
If owner is less than 18 years of age the parent or guardian shall be
deemed the owner of the dog and the application must be
completed by them.
Male, neutered $9.00 $1.00 = $10.00
Female, spayed $9.00 $1.00 = $10.00
Male, un-neutered
4 months & Over $15.00 $3.00 = $18.00
under 4 months $15.00 ----- = $15.00
Female, un-spayed
4 months & over $15.00 $3.00 = $18.00
Under 4 months $15.00 ----- = $15.00
Exempt dogs
= NO FEE
Fee
Spay/Neuter Fee TOTAL
NO FEE
For other Breed descriptions
please visit our website
Hempsteadny.gov
OWNER'S INSTRUCTIONS
1. All dogs 4 months of age or older are to be licensed. In addition, any dog under 4 months of age, if running at
large must be licensed.
2. Print all information in the appropriate boxes and sign the form.
3. Markings - please indicate if one or both ears have been cut o wholly or in part.
4. Choose from the list below one breed and one or two colors that best describes your dog and enter name and
corresponding codes on the license application.
5. Check the type of license you are applying for. Enter the corresponding statutory fee in the box to the right.
Total all fees and submit this amount to the issuing clerk.
6. For validation of this license submit in person or by mail, this application, fee, certication of spaying or neuter-
ing or proof of exemption, and proof of rabies vaccination where required to the issuing clerk in the town, city or
village where the dog is harbored.
7. Please make check payable to: KATE MURRAY, TOWN CLERK
MIXES
Collie Mix
Hound Mix
Long Hair Mix
Setter Mix
Shepherd Mix
Smooth Hair Mix
Spaniel Mix
Terrier Mix
Toy Mix
Labrador Mix
Other Mix Breed
BREEDS
Afghan Hound
Airedale Terrier
Akita
Alaskan Malamute
Am. Staordshire Terrier
Australian Terrier
Basenji
Basenji Hound
Beagle
Bichon Frise
Bloodhound
Borzois
Boston Terrier
Bouviers Des Flandres
Boxer
Brittany Spaniel
Bulldog
CODE
01
02
03
04
05
06
07
08
09
10
00
MIXES
Bullmasti
Bull Terrier
Caim Terrier
Chesapeake Bay Retriever
Chihuahua
Chow Chow
Cocker Spaniel
Collie
Daschshund
Dalmatian
Doberman Pinscher
English Cocker Spaniel
English Setter
English Springer Spaniel
Fox Terrier
German Shepard
German Shorthaired Pointer
German Wirehaired Pointer
Golden Retriever
Gordon Setter
Great Dane
Great Pyrenees
Irish Setter
Irish Wolfhound
Italian Greyhound
Japanese Chin
Kesshound
Kerry Blue Terrier
Labrador Retriever
Lhasa Apso
Maltese
CODE
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
MIXES
Manchester Terrier
Masti
Miniature Pinscher
Miniature Schnauzer
Newfoundland
Norwegin Elkhound
Old English Sheep dog
Pillon
Pekinese
Pomeranian
Poodle
Pug
Rhodesian Ridgeback
Rottweiler
St. Bernard
Saluki
Samoyed
Schipperke
Scottish Terrier
Shetland Sheepdog
Shih Terrier
Siberian Husky
Silky Terrier
Soft Coated Wheaten Terrier
Standard Schnauzer
Vizsla
Weimaraner
Welsh Corgi (Pembroke)
Welsh Terrier
West Highland White Terrier
Whippet
CODE
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
MIXES
Yorkshire Terrier
Foxhound
Coonhound
Terrier
Spaniel
Husky
Hound
Sheepdog
Other Purebred
CODE
90
92
93
94
95
96
97
98
99
COLORS
Black
Brindle
Brown (Liver)
Gold
Grey (Patched)
Red
Spotted (Patched)
Tan (Beige)
White
Apricot
Blonde
Salt & Pepper
Silver
Ticked
Yellow
Rust
Sable
Orange
Tri-Color
CODE
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
CODE
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Rev. 1/20
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