PET LICENSE APPLICATION Racine Public Health Department 730 Washington Avenue, Room 1 Racine, WI 53403 262-636-9203 [email protected] 262-636-9165 (FAX) Please be sure to complete all information. Mail, fax or email application with rabies certificate, proof of spay/neuter, and payment. Please us a separate application for each animal. Applicant Information Date:____________________________ Owner Name:______________________________ Phone:______________________________ Address:__________________________________ Email:_______________________________ Racine, WI 5340___ Your date of birth (if over 65):_____________ Please use a separate application for each animal. You may have up to 3 animals in a single family dwelling. You may obtain a Pet Fancier’s Permit ($30 fee) for up to 7 animals in a single family dwelling ONLY at the Racine Public Health Department. Each animal must be currently licensed and you must meet all criteria. Multiple family dwellings are allowed only 2 animals per unit. No Pet Fancier’s permits will be issued for multi-family dwellings. Animal Information: Dog Cat Ferret Animal Name:________________________ Rabies Manufacturer:__________________ Breed:_________________________________ Rabies Serial/Lot Number:______________ Color:__________________________________ Rabies Expiration Date:_________________ Previous City of Racine License Number:______ Veterinary Clinic:______________________ Birth Month/Year:_________________________ Male Female Neutered/Spayed (Please provide proof) Senior Discount (Altered animals only) Fee Schedule for Pet Licenses Neutered/Spayed Animal $15.00 Non-Neutered/Spayed Animal $40.00 Senior Discount (Neutered/Spayed Only) $10.00 + Late Fee $5/animal if after March 31=Total:_______ VISA AND MASTER CARD PAYMENTS ARE ACCEPTED: SEE BELOW Pet Licensing Applications may now be faxed to the Racine Public Health Department at 262-636-9165. When faxing/emailing, please be sure to include credit card information (fill-in below). Applications may also be mailed with payment included (Please do not send cash through the mail. Send a check, money order, or fill-in credit card information below). Make checks payable to "City of Racine" if mailing to the Health Department. The license, tag, and proof of rabies will be returned to you by mail. Proof of current rabies vaccination MUST accompany this form, no matter how it is submitted. Acceptable proof is the "Rabies Vaccination Certificate" you received when the vaccination was performed. Do not send metal rabies tags. A Late Fee of $5.00 per animal is charged after March 31. New animals must be licensed within 30 days of adopting them, or BEFORE turning 5 months of age. Type: Master Card Visa Name As Shown On Card: _____________________________________________________________________ Billing Address on Card if different than above __________________________________________Zip_________ Credit Card No. ________________________________________________________Expiration Date: ________ CVV Code (3 digit code on back of card): ___________ Signature ___________________________________________________ 1/2021 .