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2. 
4. Date and Time
   Date and Time

   Date and Time
6. Who is claiming the animal?
8. First Name:*
9. Last Name:*
11. Address 1:*
12. Address 2:
14. City:*
15. State:*
16. Zip:*
18. Phone Number:*
19. E-Mail:
21. Are you the owner?

    1. Yes
    2. No
23. Animal Information
25. Type
    -- Select One --DogCatOther
26. Gender

    1. Male
    2. Female
28. Description
30. Microchip
    -- Select One --YesNoUnknown
31. Spayed or Neutered
    -- Select One --YesNoUnknown
32. Valid City Tag
    -- Select One --YesNoUnknown
33. Valid Rabies Tag
    -- Select One --YesNoUnknown
35. Electronic Signature

    1. AGREEMENT:  By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

       I hereby declare that all of the above information given is true to the best of my knowledge and belief. I agree to comply with all city and state codes, ordinances and laws now in force and any others that may be enacted during the duration of requested permit.

37. Please type your first and last names:* *
38. Date**
    Date*
40. Legal Signature**

    1. I Understand

    I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document.

Leave This Blank:


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

    This field is not part of the form submission.

44. Submit

* indicates a required field