RESPONSIBLE PET OWNER CLASS PROGRAM
REGISTRATION FORM
Owner Information:
Last Name: _________________________ First Name: ___________________________
Date of Birth: ________________________ Driver’s License _________________
Address: ______________________________________________ Unit # ___________________
City: _________________________________ ZIP Code: ____________________________
Phone 1: (_______) __________________ Phone 2: (_______) ____________________
Pets:
Dog Cat Breed: _________________________ Pet’s Name: _____________________
Neutered Male Intact Male Spayed Female Intact Female
Age: ________________ Color/Description: _____________________________________________
Rabies Vaccination Date: ___________________ City License Number: _________________
Dog Cat Breed: _________________________ Pet’s Name: _____________________
Neutered Male Intact Male Spayed Female Intact Female
Age: ________________ Color/Description: _____________________________________________
Rabies Vaccination Date: ___________________ City License Number: _________________
Dog Cat Breed: _________________________ Pet’s Name: _____________________
Neutered Male Intact Male Spayed Female Intact Female
Age: ________________ Color/Description: _____________________________________________
Rabies Vaccination Date: ___________________ City License Number: _________________
Dog Cat Breed: _________________________ Pet’s Name: _____________________
Neutered Male Intact Male Spayed Female Intact Female
Age: ________________ Color/Description: _____________________________________________
Rabies Vaccination Date: ___________________ City License Number: _________________
I understand that I may choose to attend the Responsible Pet Owner Class to satisfy citations for allowing
pets to roam; failure to vaccinate against rabies; failure to purchase and display City license; or failure to
maintain sanitary conditions only. I understand that this option can be chosen only
once
within a 2-year
period. If my citations are for other violations, or if I have attended within the last two years, I understand
that I will be denied a certificate/dismissal of the citations and I will forfeit my registration fee.
Signature ________________________________________