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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

    Lombard Police Department Attention: Dog Registration 235 E. Wilson Lombard, IL 60148

Leave This Blank:


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

    This field is not part of the form submission.

41. Submit

* indicates a required field