You may prin sure to

Application Information Owner Name: Address: Racine, WI 534 Animal Information: DogPlease use a separate applicationobtain a Pet Fancier’s Permit ($27Health Department. Each animal allowed only 2 animals per unit. N Animal Name: Rabies Manufacturer: Rabies Serial/Lot Number: Rabies Expiration Date: Veterinary Clinic:

Male Female FE

VISA AND MA Pet Licensing Applications may nowplease be sure to include credit car(Please do not send cash through tpayable to "City of Racine" if mailinProof of current rabies vaccination Vaccination Certificate" you receive This application can also be submit53403 between the hours of 12 PM-6Health Division, 730 Washington Av

A Late Fee of $5.00 per animal is ch adopting them, or BEFORE turning

Type: Master Card V Name As Shown On Card: ______Billing Address on Card if differentCredit Card No. ______________ Signature ___________________

N Neutered/Spayed Animal

Non-Neutered/Spayed Animal *Senior Discount (Neutered/Spayed O

PET LICENSE APPLICATION Please complete all information.

t form to mail, fax, email, or submit in person, Please becomplete credit card information if mailing or faxing.

Racine Public Health Department 730 Washington Avenue, Room 1

Racine, WI 53403 262-636-9203

262-636-9165 (FAX)

Date: Phone:

Your date of birth (if over 65):

Cat Ferret for each animal. You may have up to 3 animals in a single family dwelling. You may .00 fee) for up to 7 animals in a single family dwelling ONLY at the Racine Publicmust be currently licensed and you must meet all criteria. Multiple family dwellings are o Pet Fancier’s permits will be issued for multi-family dwellings.

Breed:

Color:

Previous City of Racine License Number:

Birth Month/Year:

Neutered/Spayed (Please provide proof) Senior Discount (Altered animals only) E SCHEDULE FOR PET LICENSES

STER CARD PAYMENTS ARE NOW ACCEPTED: SEE BELOW be faxed to the Racine Public Health Department at 262-636-9165. When faxing/emailing,

d information (fill-in below). Applications may also be mailed with payment included he mail. Send a check, money order, or fill-in credit card information below). Make checks g to the Health Department. The license, tag, and proof of rabies will be returned to you by mail. MUST accompany this form, no matter how it is submitted. Acceptable proof is the "Rabiesd when the vaccination was performed. Do not send metal rabies tags.

ted in person to the Wisconsin Humane Society-Racine Campus, 2706 Chicory Rd, Racine, WI :30 PM Monday- Friday OR Racine Public Health Department, Environmental enue, Room 1 between the hours of 8 AM- 12 PM and 1 PM - 4:30 PM, Monday - Friday.

arged after March 31 (see above table). New animals must be licensed within 30 days of5 months of age.

isa

_______________________________________________________________ than above __________________________________________Zip_________ __________________________________________Expiration Date: ________ CCV Code: ____________(3 digit code on back of card)

________________________________

$13.00 39.00 + Late Fee if after March 31 = Total: _____________nly) 7.00 $5.00 per animal