Dog License Form:
Please
complete the following application for a dog license and submit to Town Clerk’s
Office, Town of Clay, 4401 State Route 31, Clay, New York 13041.
Please make checks payable to Vivian Mason, Town Clerk.
_____________________________________________ Phone #’s (h) _______________
(w) ___________
Owner: Last name,
First name, M.I.
______________________________________ ______________________________________
Street
Address City,
State, Zip code
Dog
breed: ______________________ Dog’s Name: ________________ Dog’s Year of Birth:
________
Dog
Color _______________________ Markings: _____________________ Other ID:
_________________
Rabies
Information: Veterinarian: ____________________________
(RABIES CERTIFICATE MUST BE SUBMITTED WITH APPLICATION)
Date of
vaccination: ____________
1 year 2 year
3 year
(Please Note: IF DOG IS SPAYED OR NEUTERED, PROOF MUST BE
SUBMITTED WITH APPLICATION or you can COMPLETE AN AFFIDAVIT FORM IN LIEU OF
CERTIFICATE.
Type
of license:
Male,
neutered $4.00
Female,
spayed $4.00
Male,
unneutered, * $12.00 * Please note: an unneutered or unspayed dog under four months pays $9.00
Female,
unspayed * $12.00
for a license, over 4 months, the cost is $12.00.
Is owner less than 18 years of age? yes no. If yes,
parent or guardian shall be deemed the owner of record; the owner of record and
the information must be completed by them.
______________________________________ __________________
Owner’s signature Date
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AFFIDAVIT FOR SPAYED OR NEUTERED DOG:
TOWN OF CLAY
__________________________________
being duly sworn, say I reside at _________________________, I am the owner of
a dog described as follows: Breed: _______________________, age ___________,
color: ____________, sex: ____________.
This dog was spayed/neutered by Dr./or Veterinarian Hospital
__________________________,
Address:
_______________________________, State of ____________________, on or about
____________________. (This affidavit
is made to obtain a license for dog described above.)
_________________________________________
Applicant’s Signature
Sworn
to before me this
___________
day of _____________ , ________
________________________________________
________________________________________
(Notary)