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2. Animal Licensing Application

   This form is to be completed by Town of Firestone residents only.

   Firestone residents who own dogs and cats must license them annually through the Firestone Police Department. All pets must have current proof of rabies vaccination before a license will be issued.

4. Are you a Firestone resident?*
   -- Select One --Yes
5. Please Note!

   The Firestone Police Department will only license animals for residents who live within the Town of Firestone jurisdiction.  Please confirm your residency before completing this form. 

7. This application is:

   1. New

   1. Renewal
9. OWNER INFORMATION
11. Animal Owner's First Name:*
12. Animal Owner's Last Name:*
14. Email Address:*
16. Street Address:*
17. P.O. Box (if applicable):
19. City*
    -- Select One --Firestone
20. Zip Code*
22. Phone Number:*
    (please give a phone number that we can reach if we have an emergency with your pet)
23. Alternate Emergency Phone Number:
27. VETERINARIAN INFORMATION
29. Veterinarian Name:*
30. Veterinarian Phone Number:*
32. Veterinarian Address, City, State, Zip Code
36. PET INFORMATION
38. Animal Name:*
39. Species:*

    1. Dog
    2. Cat
40. Gender:*

    1. Male
    2. Female
42. Breed:*
43. Microchip ID brand and number:
45. Identifying colors or markings:
47. Is your pet current on vaccination for Rabies?*

    1. Yes
    2. No

    This is a requirement and this information will need to be verified prior to receiving your pet license.
48. Rabies Certificate Tag Number:*
49. Date of Vaccination:*
    Date of Vaccination:
51. Vaccination length:*

    1. 1 year

    1. 3 years
52. Upload copy of Rabies Certificate*
54. Do you currently have a Firestone Smart Tag License?

    1. Yes

    1. No
55. Do you need a replacement tag?

    1. Yes

    1. No
57. LICENSING FEES:
58. Is your pet altered? (select one)*

    1. Spayed/Neutered - $5.00

    1. Unaltered - $10.00
60. Animal License
    Animal License
61. Taxable
62. Quantity
63. Shipping Cost
67. PET INFORMATION
69. Animal Name:
70. Species

    1. Dog
    2. Cat
71. Gender

    1. Male
    2. Female
73. Breed:
74. Microchip ID brand and number:
76. Identifying colors or markings:
78. Is your pet current on vaccination for Rabies?

    1. Yes
    2. No

    This is a requirement and this information will need to be verified prior to receiving your pet license.
79. Rabies Certificate Tag Number:
80. Date of Vaccination:
    Date of Vaccination:
82. Vaccination length:

    1. 1 year

    1. 3 years
83. Upload copy of Rabies Certificate
85. Do you currently have a Firestone Smart Tag License?

    1. Yes

    1. No
86. Do you need a replacement tag?

    1. Yes

    1. No
88. LICENSING FEES:
89. Is your pet altered? (select one)

    1. Spayed/Neutered - $5.00

    1. Unaltered - $10.00
91. Animal License
    Animal License
92. Quantity
93. Shipping Cost
94. Taxable
98. PET INFORMATION
100. Animal Name:
101. Species

     1. Dog
     2. Cat
102. Gender

     1. Male
     2. Female
104. Breed:
105. Microchip ID brand and number:
107. Identifying colors or markings:
109. Is your pet current on vaccination for Rabies?

     1. Yes
     2. No

     This is a requirement and this information will need to be verified prior to receiving your pet license.
110. Rabies Certificate Tag Number:
111. Date of Vaccination:
     Date of Vaccination:
113. Vaccination length:

     1. 1 year

     1. 3 years
114. Upload copy of Rabies Certificate
116. Do you currently have a Firestone Smart Tag License?

     1. Yes

     1. No
117. Do you need a replacement tag?

     1. Yes

     1. No
119. LICENSING FEES:
120. Is your pet altered? (select one)

     1. Spayed/Neutered - $5.00

     1. Unaltered - $10.00
122. Animal License
     Animal License
123. Quantity
124. Shipping Cost
125. Taxable
129. A nonrefundable convenience fee for all online transactions will be added upon checkout.
131. Check Here*

     1. I agree my electronic submission of this form constitutes my signature affirming the above information is true and correct.
133. Signature*
134. Date*
     Date
Leave This Blank:


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