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Dog Registration

2. Dog Registration
4. Name
5. Email Address*
7. Address*
9. City
10. State
11. Zip Code
13. Phone Number*
15. Dog Name*
17. Breed*
18. Sex*
20. Age*
21. Color*
23. Rabies Tag Number*
25. Date of Vaccination*
    Date of Vaccination
26. Vaccination Expiration Date*
    Vaccination Expiration Date
28. Photo of Dog
30. Misc. Info
    Please include info such as collar description, special markings and features, illness, injuries, etc.
32. Veterinarian's Name*
34. Veterinarian's Address*
36. Veterinarian's Phone Numer*
38. Submitted registration form will go to:
    Lombard Police Department Attention: Dog Registration 235 E. Wilson Lombard, IL 60148
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field