HomeMy WebLinkAboutPermanent Identification Verification FormADLEB—VOM/TF(Re, 10/2023) BUREAU OF DOG LAW ENFORCEMENT
PENNSYLVANIA DEPARTMENT OF AGRICULTURE
PERMANENT IDENTIFICATION
VERIFICATION FORM
MICROCHIP # or TATTOO #
WISE Bf COBREIED BY PERBCM YVLIJIII00 p18CAWMIG YILBOLBP YUBT BE L01llETEO BY CWBiY TREASUR£B PRpll TO TATTOONG
DOG'S NAME MALE FEMALE
DOG'S BREED DOG'S AGE DOG'S SEX ❑ ❑
SPOTTED WHITE BLACK BROWN OTHER —INDICATE
DOG'S COLOR/MARKINGS ❑ ❑ ❑ ❑ ❑
OWNER'S NAME
STREET
CITY
STATE
ZIP
TELEPHONE NO.
PA
TOWNSHIP
COUNTY
NAME OF PERSON Ije MICROCHIP -IMPLANTING or SCANNINGor TATroOINc
VETERINARIAN PRACTICE # (TATr000 MICROCNP)
BV
STREET
PA KENNEL LICENSE # (MICROCHIP)
COUNTY
CITY
STATE
I ZIP
TELEPHONE NO.
I MAKE THIS STATEMENT SUBJECT TO THE CRIMINAL PENALTIES OF
18 Pa. C.S. § SECTION 4904 (RELATING TO UNSWORN FALSIFICATION TO AUTHORITIES).
SIGNATURE OF PERSON IMPLANTING/SCANNING MICROCHIP/TATTOOING DATE
SIGNATURE OF DOG OWNER DATE
