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Animal License Application

2. 

4. Animal License Application

6. The Village of Channahon requires that all dogs and cats be licensed with the Village. Please provide your proof of rabies receipt from your veterinary clinic. This tag is to be renewed annually.

8. Date
   Date

10. Resident Name

12. Address

14. City

15. State

16. Zip Code

18. Phone Number

19. Cell Number

21. Email Address

23. Rabies Number

24. Rabies Due Date
    Rabies Due Date

25. Micro Chip Number

27. Animal Name

28. Sex
    -- Select One --FemaleMale

30. Breed

31. Color

32. Type
    -- Select One --CatDog

34. Vet's Name

35. Vet's Phone Number

37. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree and will provide rabies vaccination information.
39. Electronic Signature

Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit Submit and Print

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