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2. Pet Information:
4. Pets Name*
5. Species (Cat/Dog)*
6. Breed*
8. Color*
9. Tattoo or other Markings
11. Male or Female*
    -- Select One --MaleFemale
12. Age*
13. Spayed or Neutered*
    -- Select One --SpayedNeuteredNeither
15. Rabies Tag Cert. No.*
16. Upload Rabies Certificate*
18. Vaccination Date*
19. Expiration Date*
21. Microchip Brand (if applicable)
22. Microchip Number (if applicable)
24. Vet Clinic*
25. Vet Phone Number*
27. Owner Information:
29. Owner's Name*
30. Phone Number*
31. Email Address *
33. Address *
35. City
36. State
37. Zip Code
39. Alternate Contact Name and Number (Should you be out of town and your pet is lost)*
41. After your application is approved, your pet's tag will be mailed to the address provided on the form.
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field