ADLEB 14-18 REV. 11-00

DOG LICENSE APPLICATION Year of Licensure ______

License # __________________

^{NEUTERED SPAYED}

^{MALE MALE FEMALE FEMALE}

^{$8.00 $6.00 $8.00 $6.00}

¨ ¨ ¨ ¨

ABOVE PRICE INCLUDES ONE-DOLLAR SEVICE FEE ALLOWED BY LAW.

^{NEUTERED SPAYED}

^{MALE MALE FEMALE FEMALE}

^{$6.00 $4.00 $6.00 $4.00}

¨ ¨ ¨ ¨

PROOF OF DISABILITY REQUIRED.

Senior is 65 Yrs & Up

ABOVE PRICE INCLUDES ONE-DOLLAR ISSUANCE FEE ALLOWED BY LAW. I HEREBY VERIFY THAT I AM THE

OWNER OF THE DESCRIBED DOG AND ALL INFORMATION PROVIDED ON THIS APPLICATION IS TRUE AND

CORRECT. I MAKE THIS STATEMENT SUBJECT TO THE CRIMINAL PENALTIES OF 18 Pa. C.S § SECTION 4904

(RELATING TO UNSWORN FALSIFICATION TO AUTHORITIES).

ALL DOG OWNERS/APPLICANTS MUST SIGN.

____________________________________________________ DOG OWNER/APPLICANT

IF SENIOR CITIZEN, OR PERSON WITH DISABILITY, APPLICATION MUST BE SIGNED BY THE DOG OWNER.

MAIL TO THE COUNTY TREASURER'S OFFICE