"Dog License Application Form" - New York City

Dog License Application Form is a legal document that was released by the New York City Department of Health and Mental Hygiene - a government authority operating within New York City.

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Download "Dog License Application Form" - New York City

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How to Apply for a Dog License
New York City Health Code Article §161.04 requires that dogs have
a license tag attached to the collar when in public.
Save time and postage by applying for a dog license online
at
nyc.gov/doglicense
How to Apply by Mail
Fill out as much information in English as you can.
Forms submitted in other languages might take longer to process.
Select the type of license you are ordering.
Sign and date the form.
Calculate the fees using the fee table below. You may license your dog for
more than one year, unless it is under 4 months old and not spayed or neutered.
License fees are non refundable.
Attach a check or money order (not cash) for the total amount due.
Make payable to
NYC
DOHMH.
Mail the completed form and payment to:
NYC DOHMH
Citywide Dog License
P.O. Box 786002
786602
Philadelphia, PA 19178-6602
We are not responsible for lost or damaged mail.
License and Other Fees
$8.50
Spayed or Neutered, Any Age
Per year, up to 5 years
$34.00
Non-Spayed or Neutered, Over 4 Months Old
Per year, up to 5 years
$8.50
Non-Spayed or Neutered, Under 4 Months Old
First year only
$2.00
Late Fee (Expired Licenses)
For each year license was not renewed
$1.00
Replacement Tag
You can also make a donation to help the Animal Care Centers (ACC)
of NYC provide services to animals in need.
$10 can provide formula for orphaned
$500 can purchase a new cat habitat.
kittens or puppies.
$1000 can provide orthopedic surgery
$45 can spay or neuter one dog.
to an injured dog or cat.
$150 can provide obedience training.
Are you registered to vote?
If not, call 311 to obtain a voter registration form or visit www.nyccfb.info/registertovote
Call 311
nyc.gov/doglicense
or visit
for more information or to apply online.
How to Apply for a Dog License
New York City Health Code Article §161.04 requires that dogs have
a license tag attached to the collar when in public.
Save time and postage by applying for a dog license online
at
nyc.gov/doglicense
How to Apply by Mail
Fill out as much information in English as you can.
Forms submitted in other languages might take longer to process.
Select the type of license you are ordering.
Sign and date the form.
Calculate the fees using the fee table below. You may license your dog for
more than one year, unless it is under 4 months old and not spayed or neutered.
License fees are non refundable.
Attach a check or money order (not cash) for the total amount due.
Make payable to
NYC
DOHMH.
Mail the completed form and payment to:
NYC DOHMH
Citywide Dog License
P.O. Box 786002
786602
Philadelphia, PA 19178-6602
We are not responsible for lost or damaged mail.
License and Other Fees
$8.50
Spayed or Neutered, Any Age
Per year, up to 5 years
$34.00
Non-Spayed or Neutered, Over 4 Months Old
Per year, up to 5 years
$8.50
Non-Spayed or Neutered, Under 4 Months Old
First year only
$2.00
Late Fee (Expired Licenses)
For each year license was not renewed
$1.00
Replacement Tag
You can also make a donation to help the Animal Care Centers (ACC)
of NYC provide services to animals in need.
$10 can provide formula for orphaned
$500 can purchase a new cat habitat.
kittens or puppies.
$1000 can provide orthopedic surgery
$45 can spay or neuter one dog.
to an injured dog or cat.
$150 can provide obedience training.
Are you registered to vote?
If not, call 311 to obtain a voter registration form or visit www.nyccfb.info/registertovote
Call 311
nyc.gov/doglicense
or visit
for more information or to apply online.
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Dog License Application
Please print legibly.
Health Code §161.04 requires that dogs have a license tag attached to the collar when out in public.
Type of Application
❑ New
❑ Renewal
❑ Replacement Tag
Dog Owner’s information
First Name
Last Name
Address 1
Address 2
Borough
Zip Code
Phone #
E-mail
Dog’s information
Dog’s Name
Month and Year of Birth
Month (MM)
Year (YYYY)
Primary Breed
Primary Color
Secondary Color
Third Color
Gender ❑ Male
Microchip #
❑ Female
Tag #
Did your dog receive rabies vaccine?
Y es
N o
Only fill out if your dog’s rabies vaccine information has changed.
Month (MM)
Date (DD)
Year (YYYY)
Date of Vaccine
❑ 1 year
❑ 3 years
Duration
Veterinarian’s Name
Address
City
State
Zip Code
Phone #
is your dog spayed or neutered?
Y es ❑
N o
Only fill out if you have not provided proof of surgery to the Health Department in the past.
Month (MM)
Date (DD)
Year (YYYY)
Date of Surgery
Veterinarian’s Name
Address
City
State
Zip Code
Phone #
In submitting this application, I also state that the information I have provided is accurate. I recognize that making
false statements in this application violates NYC Health Code section 3.19 and other applicable law and may subject
me to civil and criminal fines and penalties, and invalidation of any license issued.
Signature
Date
Choose the license type, the number of years you would like to purchase,
and the late fee and/or replacement tag, if applicable.
Fees
1 year
2 years
3 years
4 years
5 years
Spayed or Neutered, Any Age
$ 8.50
$ 17.00
$ 25.50
$ 34.00
$ 42.50
Non-Spayed or Neutered,
A
$ 34.00
$ 68.00
$ 102.00
$ 136.00
$ 170.00
Over 4 Months
Non-Spayed or Neutered,
$ 8.50
Under 4 Months Old
x Each Year Not Renewed = $ ____________
$ 2.00
B
Late Fee for Expired License
Not Applicable
$ 1.00
Total Due
C
Replacement Tag
Not Applicable
A
B
C
D
(
+
+
+
) =
____________
$
D
ACC Donation
$ ________________
Not Applicable
For Official Use Only
License Number: ________________ License Fee: ________________
Mail with payment (check or money order payable to NYC DOHMH) to:
NYC DOHMH, Citywide Dog License, P.O. Box 786602, Philadelphia, PA 19178-6602
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