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City of Gem.Lake <br />Heritage,Hall <br />4290.Otter Lake Road 1. Gem Lake, MN 55.110 <br />-6-51-74i.-2790/92165.1-747-2795 (fax) <br />E-mail eity�ir zemlaketnn.or <br />Office.Use Only <br />Date.Issuod:- <br />Base Fee: S M00 <br />(P.ayable to City of Gem lake) <br />Receipt No. <br />..Dog License <br />Expires May 31 of each year <br />A Dog lice{tse wlll not be Issued without proof of current rabies vaccination.. Dogs under six nronths of age are not required to be <br />11penser. IfsnbMittiug by n(all, your copy ofthe rab}es cerlykate will be -returned with your (log license applicalion and tag. <br />LICENSE APPLICATION CHECKLIST: <br />To prevent -delay, please ensure the following information is-subWi ted <br />❑ Application Fee (if paying with cash we can only accept exact changa) <br />D $10.60 per dog <br />© $5.00 Lost / Replacement tag. fee <br />❑ Proof of Rabies and other Vaccinations (Current) <br />Owner Information <br />Name: <br />Address: <br />City:. <br />Homo Phone: <br />Cell Phone: <br />:State: _.Zip: <br />Would you like to have this .fotxn emailed to you. in the future? ❑. Yes. ❑ No <br />Canlnefs) Information <br />#I <br />Name: <br />'SeX: ❑ Male © Feniale Age; <br />greed: <br />COW. <br />#2 <br />Name: <br />Sex: 0. Male ❑ Female -Age: <br />Breed: <br />f� Color: <br />k <br />i <br />{ _ ................... <br />City of Gdm Lake Dog. License Page <br />