1Owner Contact2Owner Address3Owner Age / Status4Affidavit5Dog Information6Confirm Info7Payment If you looked up your record we did capture some of your info (it will not display). Please continue to fill-out the application. This field is hidden when viewing the formAppIDRenewIDThis field is hidden when viewing the formowner_idThis field is hidden when viewing the formdog_idOwner ContactFull Name(Required)Please enter your full name. First Last Email(Required)You will need to enter your email address and then re-type it to confirm. We are typing to avoid typos and get you receipt sent to the correct email. Enter Email Confirm Email Phone(Required) Physical Address(Required)Enter your physical address where the dog is living. Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Township Boro(Required)What Township or Boro will the dog be located in?Select Township or BoroADDISON BOROADDISON TWPALLEGHENY TWPBENSON BOROBERLIN BOROBLACK TWPBOSWELL BOROBROTHERSVALLEY TWPCALLIMONT BOROCASSELMAN BOROCENTRAL CITY BOROCONEMAUGH TWPCONFLUENCE BOROELK LICK TWPFAIRHOPE TWPGARRETT BOROGREENVILLE TWPHOOVERSVILLE BOROINDIAN LAKE BOROJEFFERSON TWPJENNER TWPJENNERSTOWN BOROLARIMER TWPLINCOLN TWPLOWER TURKEYFOOT TWPMEYERSDALE BOROMIDDLECREEK TWPMILFORD TWPNEW BALTIMORE BORONEW CENTERVILLE BORONORTHAMPTON TWPOGLE TWPPAINT BOROPAINT TWPQUEMAHONING TWPROCKWOOD BOROSALISBURY BOROSEVEN SPRINGS BOROSHADE TWPSHANKSVILLE BOROSOMERSET BOROSOMERSET TWPSOUTHAMPTON TWPSTONYCREEK TWPSTOYSTOWN BOROSUMMIT TWPUPPER TURKEYFOO TWPURSINA BOROWELLERSBURG BOROWINDBER BOROMailing Address Separate(Required)Do you have a SEPARATE mailing address? SELECT ONEYESNOMailing Address(Required)Enter your SEPARATE mailing address below. Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Owner Age / StatusOwner Birth Date(Required)ENTER YOUR HUMAN BIRTH DATE. MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Owner AgeYou age will display below based off of your birth date entered above.Disabled(Required)Are you disabled? Please select if your are or are not disabled.Select OneNOYES AffidavitYou are required to complete this Affidavit since you selected that you are DISABLED. Check ONE or MORE boxes below and YOU MUST click the I AGREE BOX at the bottom to continue.Affidavit Selections(Required)CHECK EACH BOX BELOW that applies to you. YOU MUST CHECK AT LEAST ONE AND CHECK AGREE AFTER THE CONSENT INFORMATION. I receive disability insurance or supplemental security income I receive a rent or property tax rebate I have a handicapped license plate I am a disabled veteran EXPLANATIONS AFFIDAVIT: 1) I receive disability insurance or supplemental security income for the AGED BLIND OR DISABLED under the Social Security Act (49 State 620 42 U.S.C. Section 301 et. seq.) 2) I receive a rent or property tax rebate under the act of March 11 1991 (P. L. 104, No. 3) known as the (Senior Citizens Rebate and Assistance Act ON ACCOUNT OF DISABILITY.) 3) I have a handicapped license plate under 75 PA C.S. Section 1338 (RELATING TO HANDICAPPED PLACE AND PLACARD.) 4) I am a disabled veteran and have a CLAIM NUMBER that I can provide if asked.Consent(Required)I hereby certify that I am the owner of the dog that is the subject of this dog license application. I further certify that I am a ‘person with a disability’ as that term is defined in Section 102 of the Pennsylvania Dog Law (P.L. 784, No. 225 as amended), in that one of more of the following above that I selected applies. I make this statement subject to the criminal penalties of 18 PA C.S. section 4904 relating to unsworn falsification to authorities. I agree Dog InformationUse the below form to add as many dogs as you need to license.Dog Info Dog Name Breed Dog Age Years Dog Age Months Actions Edit Delete There are no Dogs. Add Dog Maximum number of dogs reached. $2 PER DOG DISCOUNT APPLIED (DISCOUNT: $6.70 + $2 FEE Senior or Disabled) (REGULAR: $8.70 + $2 FEE) This field is hidden when viewing the formDog CountThis field is hidden when viewing the formDog CostPer Dog: License Total Cost Price: $0.00 Confirm Your Renewal InfoDISCOUNTS WILL ONLY BE SHOW ON THE PAYMENT SCREEN (IF YOU QUALIFY). Please review your information below for accuracy. Use the PREVIOUS BUTTON to go back and change it OR Continue to Payment. {all_fields} Payment $2 PER DOG DISCOUNT APPLIED (DISCOUNT: $6.70 + $2 FEE Senior or Disabled) (REGULAR: $8.70 + $2 FEE) Service FeeTotal processing fee ($2 PER DOG). Price: $0.00 Total Credit Card
