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2. Owner First Name*
3. Owner Last Name*
5. Owner Address*
7. Owner City*
8. Owner State*
9. Owner Zip Code*
11. Owner Phone Number*
12. Owner Email
14. Dog Breed*

    Is your dog an American Pit-Bull Terrier, Staffordshire Bull Terrier, American Staffordshire Terrier, or any mixed breed of dog which contains any of the previously mentioned breeds?

    1. Yes
    2. No
16. Upload Vet Record or Certification*
    Please upload the vet record or certification showing the following information: valid rabies vaccination,rabies expiration date, dog breed, dog gender, dog color, dog age
18. 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.
20. Electronic Signature*
Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

* indicates a required field