KATE MURRAY
Anthony
J. Santino
Supervisor
Supervisor
RABIES CERTIFICATE REQUIRED
One Year Vacc.
License #
Date Vaccinated:
Date Issued
Veterinarian:
OF F I C E O F T H E T O W N CL E R K
NA S R I N G . A H M A D
To w n Cl e r k
Expiration Date
Microchip #
Dog Breed
Code
Dog Color (s)
Code
Three Year Vacc.
One Washington Street Hempstead, NY 11550
Tel: (516) 812-3034
email: [email protected]
Dogs Birth Date
DOG’S NAME
DOG LICENSE
ORIGINAL
RENEWAL
DECEASED
TRANSFER OF
OWNERSHIP
Last Name
First Name
Phone Number
-
Mailing Address
-
City
Apt. #
State
Zip Code
N Y
Fee
County
N A S S A U
Spay/Neuter Fee
TOTAL
Town
H E M P S T E A D
Male, neutered
$9.00
$1.00
=
$10.00
T.O.H. Fee $
Female, spayed
$9.00
$1.00
=
$10.00
N.Y. State Fee $
4 months & Over
$15.00
$3.00
=
$18.00
under 4 months
$15.00
-----
=
$15.00
4 months & over $15.00
$3.00
=
$18.00
Under 4 months $15.00
-----
=
$15.00
=
NO FEE
Male, un-neutered
Total Fee $
Female, un-spayed
Exempt dogs
NO FEE
If owner is less than 18 years of age the parent or guardian
shall be deemed the owner of the dog and the
application must be completed by them.
Rev.
Rev.1-16
12-14WW
Owner’s Signature
Town Clerk
Date
Date
OWNER'S INSTRUCTIONS
1. All dogs 4 months of age or older are to be licensed. In addition, any dog under 4 months of age, if running at
large must be licensed.
2. Print all information in the appropriate boxes and sign the form.
3. Markings - please indicate if one or both ears have been cut off wholly or in part.
4. Choose from the list below one breed and one or two colors that best describes your dog and enter name and
corresponding codes on the license application.
5. Check the type of license you are applying for. Enter the corresponding statutory fee in the box to the right.
Total all fees and submit this amount to the issuing clerk.
6. For validation of this license submit in person or by mail, this application, fee, certification of spaying or neutering or proof of exemption, and proof of rabies vaccination where required to the issuing clerk in the town, city or
village where the dog is harbored.
7. Please make check payable to: NASRIN G. AHMAD, TOWN CLERK
MIXES
CODE
Bullmastiff
28
Bull Terrier
29
Caim Terrier
30
Chesapeake Bay Retriever
31
32
Chihuahua
33
Chow Chow
34
Cocker Spaniel
35
Collie
36
Daschshund
Dalmatian
37
Doberman Pinscher
38
English Cocker Spaniel
39
English Setter
40
41
BREEDS
CODE English Springer Spaniel
42
Afghan Hound
11 Fox Terrier
43
Airedale Terrier
12 German Shepard
Akita
13 German Shorthaired Pointer 44
Alaskan Malamute
14 German Wirehaired Pointer 45
46
Am. Staffordshire Terrier 15 Golden Retriever
47
Australian Terrier
16 Gordon Setter
48
Basenji
17 Great Dane
49
Basenji Hound
18 Great Pyrenees
50
Beagle
19 Irish Setter
51
Bichon Frise
20 Irish Wolfhound
52
Bloodhound
21 Italian Greyhound
53
Borzois
22 Japanese Chin
54
Boston Terrier
23 Kesshound
55
Bouviers Des Flandres 24 Kerry Blue Terrier
56
Boxer
25 Labrador Retriever
57
Brittany Spaniel
26 Lhasa Apso
58
Bulldog
27 Maltese
MIXES
Collie Mix
Hound Mix
Long Hair Mix
Setter Mix
Shepherd Mix
Smooth Hair Mix
Spaniel Mix
Terrier Mix
Toy Mix
Labrador Mix
Other Mix Breed
Rev. 12-14 W
CODE
01
02
03
03
05
06
07
08
09
10
00
MIXES
CODE
Manchester Terrier
59
Mastiff
60
Miniature Pinscher
61
Miniature Schnauzer
62
Newfoundland
63
Norwegin Elkhound
64
Old English Sheep dog
65
Pillon
66
Pekinese
67
Pomeranian
68
Poodle
69
Pug
70
Rhodesian Ridgeback
71
Rottweiler
72
St. Bernard
73
Saluki
74
Samoyed
75
Schipperke
76
Scottish Terrier
77
Shetland Sheepdog
78
Shih Terrier
79
Tzu
Siberian Husky
80
Silky Terrier
81
Soft Coated Wheaten Terrier 82
Standard Schnauzer
83
Vizsla
84
Weimaraner
85
Welsh Corgi (Pembroke)
86
Welsh Terrier
87
West Highland White Terrier 88
Whippet
89
For other Breed descriptions
please visit our website toh.li
MIXES
Yorkshire Terrier
Foxhound
Coonhound
Terrier
Spaniel
Husky
Hound
Sheepdog
Other Purebred
CODE
90
92
93
94
95
96
97
98
99
COLORS
Black
Brindle
Brown (Liver)
Gold
Grey (Patched)
Red
Spotted (Patched)
Tan (Beige)
White
Apricot
Blonde
Salt & Pepper
Silver
Ticked
Yellow
Rust
Sable
Orange
Tri-Color
CODE
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S