Village of Barneveld Dog/Cat License Application

Owner Name _______________________________________________

Address ___________________________________________________

             ___________________________________________________

             _________________________ Phone Number______________

Name of Dog/Cat __________Breed: _________ Color ____________

CHECK ONE:

___Spayed Female($3) ___Neutered Male ($3) ___Unspayed Female($8) ___Unneutered Male($8)

Rabies Vaccination Information

Veterinarian_____________       Serial Number__________________

Vaccination Date_________       Expiration Date_________________