AUDITOR’S OFFICE

DOG LICENSE APPLICATION FORM

DOG OWNER: By purchasing a Montgomery County Dog License and providing the information requested below, you will be protecting
your pet should it become lost and helping to fund the Montgomery County Animal Resource Center. All license fees and donations go
directly to the operation of the Animal Resource Center for the rescue, care and housing of our community's lost and homeless dogs.

Licenses are to be renewed annually between December 1st and January 31st. Renewal tags bought after January 31st are
subject to late fees.

Owner Name Second Owner Name

([ ]) ([ ])
Primary Phone Secondary Phone Owner Email

Owner Address

Owner City, State ZIP Code

DOG INFORMATION

M F Short Medium Long Unknown

Previous Tag Number (If known) Sex (circle one) Hair/Coat (circle one)

Most Dominant Color Second Most Dominant Color Third Most Dominant Color

Breed Microchip Number

Years Months (If less than 1 year old) Standard Oval ($20) * Bone ($25) **Heart ($30)
Age Tag Shape (circle one)

*Required $5 Minimum Donation per Dog

**Required $10 Minimum Donation per Dog

Date the dog was acquired or moved into the State of Ohio (if applicable).

Signature Date

Please print the application, make check payable to the Montgomery County Auditor and mail to:

Karl L. Keith
Montgomery County Auditor
P.O. Box 972
Dayton, OH 45422-1031