License Number:
Date Issued:
Valid for Period:     07/01/2004-06/30/2005

Owner Information
First Name:
Last Name:
Address where dog lives:
City:
State:
Zip Code:
Mailing Address:
City:
State:
Zip Code:
Ward where dog lives:
Home Phone:
Work Phone:

Dog Information
Breed:
Name:
Sex:	Male   Female  Spayed Female:   Neutered Male:
Age:
Color:

Vaccination Information
Rabies Vaccination Date:*	1 Year   3 Year
Distemper Vaccination Date:*
Rabies Tag #:

License Fee
Fee for Sterilized Dog:	$13**
Fee for Unsterilized Dog:	$46
Person Issuing License:
Transaction Date:
Comments:

*Proof of rabies and distemper vaccination must accompany this form.

**Proof of sterization must accompany this form.

Make check or money order to DC Treasurer.

Send Application to:
Department of Health
Animal License Division
51 N Street, NE
Suite 6002
Washington, DC 20002
(202) 535-2325/2323

* Once you complete this form, click the View Form button to review and print the form.