Original Dog License
Application
Rabies
Vaccination
Information
Date:
Manufacturer
Tag #
Lenght of Vacc.
Vet's name
First Name Last NameMiddle Initial
Street #
Physical Home
Address
Street Name
Apt # City
State ZIP
Mailing
Address
(if different)
Street #
Apt #
State
Street Name
City
ZIP
PO BOX
Type of License
Spay/Neuter Fee
Dog Info
Breed Code
Primary Color
Secondary Color
Tattoo #
Markings
Dogs Name Birth Year
Phone # Email Address (optional)
Owner Info
TOTAL DUE
Please Use the Dog License Application Instruction Sheet When Completing this Form
Gender
Include a Copy of the
Rabies Certificate
Mail Application, Rabies Certificate
and Check to:
Town Clerk
20 Middlebush Road
Wappingers Falls, NY 12590
If Neutered or Spayed,
Include a Copy of the
Neuter/Spay Certificate
2011-01-25 JCM
Print Form
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