City of Tekoa - Dog Licensing Form - 2011
Owner's Name: Telephone No.:
Owner's Address: Work or Cell Phone No:
Owner's Physical Address:
DOG #1 ~ Name of Dog:
Breed of Dog: Male or Female:
Please circle: Spayed Neutered Not altered Color:
Rabies Vaccination Certificate No_____________ Dog Tag No._________
(copy of certificate must be attached)
DOG #2 ~ Name of Dog:
Breed of Dog: Male or Female:
Please circle: Spayed Neutered Not altered Color:
Rabies Vaccination Certificate No_____________ Dog Tag No._________
DOG #3 ~ Name of Dog:
Breed of Dog: Male or Female:
Please circle: Spayed Neutered Not altered Color:
Rabies Vaccination Certificate No_____________ Dog Tag No._________
DOG #4 ~ Name of Dog:
Breed of Dog: Male or Female:
Please circle: Spayed Neutered Not altered Color:
Rabies Vaccination Certificate No_____________ Dog Tag No._________
TO BE FILLED OUT BY CITY CLERK
DATE ISSUED:_________________ TAG NUMBER (S):_____\_____\_____\_____
FEE CHARGED:____________ LATE FEE?_________ LOST TAG? __________
It is hereby acknowledged that I received from the above named dog owner,
$______________ on this date for the above listed dog(s).
This license will expire at the beginning of the next calendar year.
Signed:_________________________________________________
Clerk/Treasurer – City of Tekoa
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