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2. 
4. Animal License Application
6. The Village of Channahon requires that all dogs and cats be licensed with the Village. This tag is to be renewed annually. Please provide your proof of rabies receipt from your veterinary clinic. You may also provide a photo of your pet to add to our database if you wish. Proof of rabies receipts and photos can be uploaded via this form or sent to mmazintas@channahon.org.
10. Pet Owner Information
12. Date
    Date
14. Resident Name*
16. Address*
18. City*
19. State*
20. Zip Code*
22. Phone Number*
23. Cell Number
25. Email Address*
29. Pet #1 Information
31. Rabies Number *
32. Rabies Due Date*
    Rabies Due Date
33. Micro Chip Number
35. Animal Name*
36. Sex*
    -- Select One --FemaleMale
38. Breed*
39. Color*
40. Type*
    -- Select One --CatDog
42. Spayed/Neutered?*

    1. Yes
    2. No
43. Collar Description*
45. Vet's Name*
46. Vet's Phone Number*
48. Proof of Rabies Vaccination

    Please upload proof of your pet's rabies vaccination. If you prefer, you may also email a copy to mmazintas@channahon.org.

50. Pet Photo

    If you wish, you may upload a photo of your pet to be included in our database. If you prefer, you may also email a photo to mmazintas@channahon.org.

54. Pet #2 Information
56. Rabies Number
57. Rabies Due Date
    Rabies Due Date
58. Micro Chip Number
60. Animal Name
61. Sex
    -- Select One --MaleFemale
63. Breed
64. Color
65. Type
    -- Select One --DogCat
67. Spayed/Neutered?

    1. Yes
    2. No
68. Collar Description
70. Vet's Name
71. Vet's Phone Number
73. Proof of Rabies Vaccination

    Please upload proof of your pet's rabies vaccination. If you prefer, you may also email a copy to mmazintas@channahon.org

75. Pet Photo

    If you wish, you may upload a photo of your pet to be included in our database. If you prefer, you may also email a photo to mmazintas@channahon.org

79. Pet #3 Information
81. Rabies Number
82. Rabies Due Date
    Rabies Due Date
83. Micro Chip Number
85. Animal Name
86. Sex
    -- Select One --MaleFemale
88. Breed
89. Color
90. Type
    -- Select One --CatDog
92. Spayed/Neutered?

    1. Yes
    2. No
93. Collar Description
95. Vet's Name
96. Vet's Phone Number
98. Proof of Rabies Vaccination

    Please upload proof of your pet's rabies vaccination. If you prefer, you may also email a copy to mmazintas@channahon.org

100. Pet Photo

     If you wish, you may upload a photo of your pet to be included in our database. If you prefer, you may also email a photo to mmazintas@channahon.org.

104. Pet #4 Information
106. Rabies Number
107. Rabies Due Date
     Rabies Due Date
108. Micro Chip Number
110. Animal Name
111. Sex
     -- Select One --MaleFemale
113. Breed
114. Color
115. Type
     -- Select One --DogCat
117. Spayed/Neutered?

     1. Yes
     2. No
118. Collar Description
120. Vet's Name
121. Vet's Phone Number
123. Proof of Rabies Vaccination

     Please upload proof of your pet's rabies vaccination. If you prefer, you may also email a copy to mmazintas@channahon.org.

125. Pet Photo

     If you wish, you may upload a photo of your pet to be included in our database. If you prefer, you may also email a photo to mmazintas@channahon.org

129. 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.
131. Electronic Signature*
Leave This Blank:


133. 1. Receive an email copy of this form.
134. Email address

     This field is not part of the form submission.

135. Submit Submit and Print

* indicates a required field