2. First Name
3. Last Name
5. Street Address
7. City
8. State
9. Zip Code
11. Phone
12. Email
14. Pet's Name
15. Breed
16. Color(s)
18. Age or D.O.B.
19. Microchip # if applicable
20. Rabies Tag # and Expiration
22. Please check one option:

    1. Dog/Cat Annual ($10)
    2. Dog/Cat Lifetime ($50)
    3. Replacement Tag ($5)
23. PRIVACY NOTICE

    I understand the information provided in this form may be considered private or confidential data. I further understand that I may not be required by law to provide such information. The purpose of providing such information is to aid the City in its determination on said application. I acknowledge that providing, or failing to provide, such information may affect the City’s determination on said application. I understand this information will be made available to the City of Mounds View, its City Council, agents and representatives, as well as the Minnesota Department of Revenue, the Internal Revenue Service, or any other person or entity authorized by law to receive said information. I release the City of Mounds View from any and all liability for its receipt and use of data received pursuant to this application. 

25. Rabies Certificate
27. 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.
29. Electronic Signature
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field