AN
NIMAL LICEENSE APPLLICATION
City of EElk Grove, 840
01 Laguna Palms Way, Elk Grove CA 95758 (916) 687
7‐3042 www.elkgrovecity.org FAILURE TO
O LICENSE YO
OUR ANIMAL MAY RESULTT IN FINES AN
ND FEES UP TO
O $500 OWNER
R INFORMATIION Owner Nam
me _________
__________________________________________________________________________ Home Address ________
_________________________ Mailing Address ________________________________ City, State, ZZip ________
_________________________ City, Staate, Zip ____________________________
______ Home Phon
ne _________
_____________ Work ______________________ Cell ___________________________ Email Addreess ________
__________________________________________________________________________ Emergency Contact_____
_________________________________________________________________________ Home Phon
ne _________
_____________ Work ______________________ Cell ___________________________ INSSTRUCTIONS
Please provvide the following with your application
n to 8401 LAG
GUNA PALMSS WAY: Rab
bies certificate: Required and must be current. Miccrochip registtration card o
or pay the yeaarly Microchip
p Exemption FFee. (REQUIR
RED) Spaay/Neuter cerrtificate: To b
be eligible for the altered fee if it has no
ot already beeen provided)
• If your animal cannott be spayed or neutered fo
or medical rea
asons, a letteer from a licen
nsed nse fee. veterinarian IS REQUIRED to receive a discountt of one‐half ((0.5) of the unaltered licen
Sen
nior Citizen Diiscount: For citizens 65 an
nd older (ID R
Required with
h City of Elk Grove Addresss) • Altered FFee (2 pet per household llimit) Servvice Dog: Serrvice Dog Affid
davit available at the Cash
hier's Departm
ment Payyment : Mail o
or Pay in Persson to the Casshier's Department located at 8401 Lagguna Palms W
Way, Elk Gro
ove CA 95758. Please make checks payable to City o
of Elk Grove.
LICENSEE INFORMATIION ANIMAL INFORMATION FEE RATE Animal’s Naame________
____________
___________
(Please circle your sele
ection) Microchip B
Brand ______
______________________
Microchip ## __________
______________________ R9 UNALTER
RED R1 ALTER
RED Rabies Expirration Date __
___/____/_____________ 1 Year Liceense $
$50 $
$15 3 Year Liceense $1
150 $
$35 $
$25 Age ____________ DOB_____/______/_____ Senior Citizzen License $0 Male/Female _____ Spayyed/Neutered
d _________ Service Do
og License
$0 $0 Primary Breeed ________
______________________
Miscellane
eous: Secondary B
Breed ______
______________________
Microchip Exemption Fee (yearly) ASSM $
$50 Color _________________
_____________________
A
$
$15 Late Fee ASO01
Size Sm
mall 1‐20 lbs. $5 Replacemeent Tag (if neeeded) R1 Meedium 21‐49 lbs. Larrge 50+ lbs $___________ Total Licen
nse Fee Enclosed Any distingu
uishing markss? REV. 05/14/14