ADLEB 19 Rev 9 PA Department of Agriculture 2023-2026

ADLEB 19 rev. 9/2014 PA Department of Agriculture Bureau of Dog Law Enforcement LIFETIME DOG LICENSE APPLICATION Year of license A Permanent Identification Verification Form must be completed before the license will be issued. DOG OWNER S NAME OWNER S BIRTHDATE PHONE NUMBER MO. DAY YR. STREET ADDRESS TOWNSHIP/BOROUGH CITY STATE ZIP CODE PA DATE BREED COLOR / MARKINGS SPOTTED DOG S AGE WHITE BLACK REGULAR LIFETIME LICENSE DOG S NAME BROWN OTHER-INDICATE PERSON WITH DISABILITY OR SENIOR CITIZEN FEE NEUTERED SPAYED NEUTERED SPAYED MALE MALE FEMALE FEMALE MALE MALE FEMALE FEMALE 51. 50 31. 50 51. 50 31. 50 31. 50 21. 50 31. 50 21. 50 ALL PRICES INCLUDE SERVICE FEES ALLOWED BY LAW PLEASE NOTE If you are applying for a lifetime license that requires the dog owner be a senior citizen age 65 or older or a person with disability you must provide proof of age or disability to the County Treasurer. I HEREBY VERIFY THAT I AM THE OWNER OF THE DOG THAT IS THE SUBJECT OF THIS DOG LICENSE APPLICATION. I MAKE THIS STATEMENT SUBJECT TO THE CRIMINAL PENALTIES OF 18 Pa SECTION 4904 RELATING TO UNSWORN FALSIFICATION TO AUTHORITIES. I HEREBY VERIFY THAT I AM THE OWNER OF THE DOG THAT IS THE SUBJECT OF THIS DOG LICENSE APPLICATION. I MAKE THIS STATEMENT SUBJECT TO THE CRIMINAL PENALTIES OF 18 Pa SECTION 4904 RELATING TO UNSWORN FALSIFICATION TO AUTHORITIES. SIGNATURE OF DOG OWNER/APPLICANT REQUIRED IF APPLICANT IS A MINOR SIGNATURE OF PARENT OR GUARDIAN IS REQUIRED MAIL TO COUNTY TREASURER S OFFICE ADLEB VOM/TF DOG LAW ENFORCEMENT OFFICE PENNSYLVANIA DEPARTMENT OF AGRICULTURE PERMANENT IDENTIFICATION VERIFICATION FORM MICROCHIP or MUST BE COMPLETED BY PERSON IMPLANTING OR SCANNING MICROCHIP TATTOO DOG S NAME DOG S BREED DOB DOG S SEX SPOTTED WHITE BLACK BROWN OTHER INDICATE DOG S COLOR/MARKINGS STREET ZIP TELEPHONE NO. SIGNATURE OF DOG OWNER/APPLICANT REQUIRED IF APPLICANT IS A MINOR SIGNATURE OF PARENT OR GUARDIAN IS REQUIRED MAIL TO COUNTY TREASURER S OFFICE ADLEB VOM/TF DOG LAW ENFORCEMENT OFFICE PENNSYLVANIA DEPARTMENT OF AGRICULTURE PERMANENT IDENTIFICATION VERIFICATION FORM MICROCHIP or MUST BE COMPLETED BY PERSON IMPLANTING OR SCANNING MICROCHIP TATTOO DOG S NAME DOG S BREED DOB DOG S SEX SPOTTED WHITE BLACK BROWN OTHER INDICATE DOG S COLOR/MARKINGS STREET ZIP TELEPHONE NO. TOWNSHIP COUNTY NAME OF PERSON circle one MICROCHIP-IMPLANTING or SCANNING or TATTOOING VETERINARIAN PRACTICE TATTOO or MICROCHIP PA KENNEL LICENSE MICROCHIP BV COUNTY I MAKE THIS STATEMENT SUBJECT TO THE CRIMINAL PENALTIES OF 18 Pa. C. I HEREBY VERIFY THAT I AM THE OWNER OF THE DOG THAT IS THE SUBJECT OF THIS DOG LICENSE APPLICATION* I MAKE THIS STATEMENT SUBJECT TO THE CRIMINAL PENALTIES OF 18 Pa SECTION 4904 RELATING TO UNSWORN FALSIFICATION TO AUTHORITIES. SIGNATURE OF DOG OWNER/APPLICANT REQUIRED IF APPLICANT IS A MINOR SIGNATURE OF PARENT OR GUARDIAN IS REQUIRED MAIL TO COUNTY TREASURER S OFFICE ADLEB VOM/TF DOG LAW ENFORCEMENT OFFICE PENNSYLVANIA DEPARTMENT OF AGRICULTURE PERMANENT IDENTIFICATION VERIFICATION FORM MICROCHIP or MUST BE COMPLETED BY PERSON IMPLANTING OR SCANNING MICROCHIP TATTOO DOG S NAME DOG S BREED DOB DOG S SEX SPOTTED WHITE BLACK BROWN OTHER INDICATE DOG S COLOR/MARKINGS STREET ZIP TELEPHONE NO.