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2. Name*
4. Phone Number*
6. How many dogs are you applying for today?*
   -- Select One --1234
8. Dog Name*
10. Gender*

    1. Male
    2. Female
12. Altered (Spay/Neuter)*

    1. Yes
    2. No
14. Breed*
16. Veterinarian Clinic*
18. Rabies Vaccination Expiration Date*
    Rabies Vaccination Expiration Date
20. Dog Name
22. Gender

    1. Male
    2. Female
24. Altered (Spay/Neuter)

    1. Yes
    2. No
26. Breed
28. Veterinarian Clinic
30. Rabies Vaccination Expiration Date
    Rabies Vaccination Expiration Date
32. Dog Name
34. Gender

    1. Male
    2. Female
36. Altered (Spay/Neuter)

    1. Yes
    2. No
38. Breed
40. Veterinarian Clinic
42. Rabies Vaccination Expiration Date
    Rabies Vaccination Expiration Date
44. Dog Name
46. Gender

    1. Male
    2. Female
48. Altered (Spay/Neuter)

    1. Yes
    2. No
50. Breed
52. Veterinarian Clinic
54. Rabies Vaccination Expiration Date
    Rabies Vaccination Expiration Date
56. Proof of Rabies vaccination must be received within 5 days of payment. Failure to do so will result in your payment being forfeited and no license will be issued.

    For your convenience, there are several submission options available:

    • Mail or in-person: 118 W Maple, Centralia, WA 98531
    • Fax: 360-807-6210
    • Email Police Records

    1. I agree to provide proof of rabies within 5 days
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58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field