HomeMy WebLinkAboutLifetime Dog License ApplicationADLEB 19 rev. 9/2014
PA Department of Agriculture, Bureau of Dog Law Enforcement
LIFETIME DOG LICENSE APPLICATION
Year of license
A Permanent Identification Verification Form must be completed before the license will be issued.
DOG OWNER’S NAME OWNER’S BIRTHDATE PHONE NUMBER
MO. DAY YR.
STREET ADDRESS TOWNSHIP/BOROUGH
CITY STATE ZIP CODE
DATE BREED DOG’S AGE DOG’S NAME
COLOR / SPOTTED WHITE BLACK BROWN OTHER-INDICATE
MARKINGS
REGULAR LIFETIME LICENSE PERSON WITH DISABILITY
OR SENIOR CITIZEN FEE
NEUTERED SPAYED NEUTERED SPAYED
MALE MALE FEMALE FEMALE MALE MALE FEMALE FEMALE
$51.50 $31.50 $51.50 $31.50 $31.50 $21.50 $31.50 $21.50
PLEASE NOTE: If you are applying for a lifetime license that requires the dog owner be a senior citizen (age 65 or
older) or a person with disability, you must provide proof of age or disability to the County Treasurer.
I HEREBY VERIFY THAT I AM THE OWNER OF THE DOG THAT IS THE SUBJECT OF THIS DOG LICENSE
APPLICATION. I MAKE THIS STATEMENT SUBJECT TO THE CRIMINAL PENALTIES OF 18 Pa § SECTION 4904
(RELATING TO UNSWORN FALSIFICATION TO AUTHORITIES).
SIGNATURE OF DOG OWNER/APPLICANT REQUIRED
IF APPLICANT IS A MINOR, SIGNATURE OF PARENT OR GUARDIAN IS REQUIRED
MAIL TO COUNTY TREASURER’S OFFICE
PA
ALL PRICES INCLUDE SERVICE FEES
ALLOWED BY LAW
ALL PRICES INCLUDE SERVICE FEES
ALLOWED BY LAW