OFFICE OF THE TOWN CLERK
One Washington Street Hempstead, NY 11550
Tel: (516) 812-3034 email: licensing@tohmail.org
ORDER FOR REPLACEMENT ID TAG OR PUREBRED TAG OR TAGS
2 Copies
White - T.O.H. Copy
Yellow - Owner
Rev. 1-16
Replacement I.D. Tag #
Old license # ( Office use only )
Date: _________ Total amount received: _______________ Signature of Clerk: _______________________
Street Address: __________________________________ City: _________________ Zip Code:________
I hereby affirm under penalty of perjury that the information provided on this form is true to the best of my knowledge and
belief. False statements made herein are punishable pursuant to section 210.45 of the penal law.
Name of Owner: _____________________________________________________
Signature of Owner: _________________________ Date: ________________
Please return this form with Check or Money Order to the
Town of Hempstead Clerk’s Office
Please do not mail cash
Please do not mail cash
County of: ___________
Total $ 3.00
Quality: 1 @ $3.00
Purchase of Purebred Tag(s) #
NASSAU
Town of: ______________
HEMPSTEAD
OFFICE OF THE TOWN CLERK
One Washington Street Hempstead, NY 11550
Tel: (516) 812-3034 email: licensing@tohmail.org
ORDER FOR REPLACEMENT ID TAG OR PUREBRED TAG OR TAGS
2 Copies
White - T.O.H. Copy
Yellow - Owner
Rev. 1-16
Replacement I.D. Tag #
Old license # ( Office use only )
Date: _________ Total amount received: _______________ Signature of Clerk: _______________________
Street Address: __________________________________ City: _________________ Zip Code:________
I hereby affirm under penalty of perjury that the information provided on this form is true to the best of my knowledge and
belief. False statements made herein are punishable pursuant to section 210.45 of the penal law.
Name of Owner: _____________________________________________________
Signature of Owner: _________________________ Date: ________________
Please return this form with Check or Money Order to the
Town of Hempstead Clerk’s Office
County of: ___________
Total $ 3.00
Quality: 1 @ $3.00
Purchase of Purebred Tag(s) #
NASSAU
Town of: ______________
HEMPSTEAD
