HomeMy WebLinkAboutPermanent Identification Verification FormADLEB—VOM/TF
PENNSYLVANIA BUREAU OF DOG LAW ENFORCEMENT
PERMANENT IDENTIFICATION VERIFICATION FORM
MICROCHIP TATTOO
MICROCHIP# or TATTOO#
MUST BECOMPLETED BY PERSON IMPLANTINGORSCANNINGMICROCHIP MUSTBE COMPLETED BY COUNTY TREASURERPRIOR TO TATTOOING
DOG'S NAME NEUTERED SPAYED
MALE MALE FEMALE FEMALE
DOG'S BREED DOB DOG'S SEX
SPOTTED WHITE BLACK BROWN OTHER-INDICATE
DOG'S COLOR/MARKINGS
OWNER'S NAME STREET OR R.D.NO.
CITY STATE ZIP TELEPHONE NO.
PA
TOWNSHIP COUNTY
NAME OF PERSONcircle one MICROCHIP-IMPLANTING or SCANNINGor TATTOOING VETERINARIAN PRACTICE#(rArroo or MICROCHIP)
BV
STREET OR R.D.NO PA KENNEL LICENSE#(MICROCHIP)
COUNTY CITY STATE 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 MICROCHIPITATTOOING DATE
SIGNATURE OF DOG OWNER DATE
FORM MUSTBE RETURNED TO COUNTY 1RE4SURER YVIIFNN 30 DAYS OF RECEIPT
Form is VOID if not returned to Treasurer on or before date listed