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Application Along with the Following Items to Complete Your Application: Completed Service Dog License Agreement Affidavit Provide Current Rabies Certificate

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Application Along with the Following Items to Complete Your Application: Completed Service Dog License Agreement Affidavit Provide Current Rabies Certificate Animal Care Services 660 Orange Avenue, Beaumont, CA 92223 951.769.8500 Fax 951.769.8526 www.beaumontpd.org SERVICE ANIMAL CHECKLIST Please Return the Attached Application Along with the Following Items to Complete your Application: Completed Service Dog License Agreement Affidavit Provide current Rabies Certificate. The certificate must include what type of vaccine given, lot number and manufacturer. Must cover at least one year for licensing. Rabies vaccination cannot be expired past 30 days to be honored as a 3 year vaccination. Proof of spay/neuter certificate if your dog is altered. Copy of State issued Identification, Driver’s License or Passport to verify residency. Provide any information or documentation of how this service dog assists you to determine they meet the criteria. According to ADA Standards, it is a violation to ask what your disability is; however, we can ask what this dog does for your disability. Proof of service training for your dog if you are applying as a handler. Please resend the requested information to expedite the process. Thank you in advance for your cooperation. Also, all tags are permanent and should be returned to Beaumont Animal Control Services upon death or transfer of the animal to another owner or out of the jurisdiction of the City of Beaumont and/or Calimesa. If you have any questions, please don’t hesitate to contact me. Sincerely, Sean Thuilliez Chief of Police By: Jeremy Dorrough, Police Lieutenant Department of Animal Control Services (951) 769-8500 ASSISTANCE DOG IDENTIFICATION TAG APPLICATION Rev. 11/2018 Animal Care Services 660 Orange Avenue, Beaumont, CA 92223 951.769.8500 Fax 951.769.8526 www.beaumontpd.org ASSISTANCE DOG IDENTIFICATION APPLICATION DATE: _____/______/_______ DOG OWNER INFORMATION: (Please Print) Name: _______________________________________ Phone: _________________________ Mailing Address: ______________________________ Other Phone: ____________________ City: _____________________________________ Zip Code: __________________________ Physical Address Where Dog Housed: ___________________________________________ (If Different Than Above) DOG INFORMATION: (Please Print) Name: ___________________ Breed: ________________Color:_____________ Sex:_____ Age: _____ License ID: _______________ Expires: _____________ Microchip No.:_______________________ Tattoo#:___________________ 1. IS THE DOG A SERVICE ANIMAL REQUIRED BECAUSE OF A DISABILITY? YES or NO 2. WHAT WORK OR TASK HAS THE DOG BEEN TRAINED TO PERFORM? TRAINING PROVIDED BY: ________________________________________________ ASSISTANCE DOG IDENTIFICATION TAG APPLICATION Rev. 11/2018 Animal Care Services 660 Orange Avenue, Beaumont, CA 92223 951.769.8500 Fax 951.769.8526 www.beaumontpd.org Food and Agriculture Code 30850(b), Whenever a person applies for an assistance dog identification tag, the person shall sign an affidavit stating as follows: By affixing my signature to this affidavit, I hereby declare I fully understand that Section 365.7 of the Penal Code prohibits any person to knowingly and fraudulently represent himself or herself, through verbal or written notice, to be the owner or trainer of any canine licensed as, to be qualified as, or identified as, a guide dog, signal dog, or service dog, as defined in subdivisions (d), (e), and (f), respectively, of Section 365.5 of the Penal Code and paragraph (6) of subdivision (b) of Section 54.1 of the Civil Code, and that a violation of Section 365.7 of the Penal Code is a misdemeanor, punishable by imprisonment in a county jail not exceeding six months, by a fine not exceeding one thousand dollars ($1,000), or by both that imprisonment and fine. (c) Upon the death or retirement of an assistance dog, the owner or person in possession of the assistance dog identification tag shall immediately return the tag to the animal control department that issued the tag. (Enacted 1994, amended 2004) Penal Code 365.6 (2)"Guide, signal, or service dog" means any dog trained to do work or perform tasks for the benefit of an individual with a disability, including, but not limited to, guiding individuals with impaired vision, alerting individuals with impaired hearing to intruders or sounds, pulling a wheelchair, or fetching dropped items. Food and Agriculture Code Section 30850 (a) The animal control department shall endorse upon the application for an assistance dog identification tag the number of the identification tag issued. As used in this chapter, "assistance dogs" are dogs specially trained as guide dogs, signal dogs, or service dogs. All applications that have been endorsed shall be kept on file in the office of the animal control department and shall be open to public inspection. Section 30852 (a)The tag identifying a dog as an assistance dog shall be used only by a person with a disability or a trainer of an assistance dog and shall be of such uniform statewide shape, size, and color as to be easily recognized. Please read, sign and date below: I certify, under penalty of perjury, that I am the owner of the above described dog and that the dog is used solely and entirely for the purpose of providing personal service to me as described in X SIGNATURE DATE FOR OFFICE USE ONLY: LICENSE STATUS VERIFIED: (circle) YES or NO ASSISTANCE TAG #: TASK DIRECTLY RELATED TO DISABILITY: (circle) YES or NO BY: ________________________ APPLICATION APPROVED / DENIED BY:_________________________ DATE: ASSISTANCE DOG IDENTIFICATION TAG APPLICATION Rev. 11/2018 .
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