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City of Buckner
004 West Monroe
P.O. Box 377 Buckner, Missouri 64106-0377


ANIMAL REGISTRATION FORM

Tag(s) # 


___ DOG NUMBER (LIMIT 4)
___ CAT NUMBER (LIMIT 4)
___ OTHER NUMBER (LIMIT 4)

Owners will provide 2 color photos (one frontal view & one side view) of EACH animal to be licensed.


PET(S)DESCRIPTION: 







OWNER(S) NAME:





OWNER (S) ADDRESS:





OWNER (S) PHONE:  

EMERGENCY CONTACT (NAME AND PHONE):



RECEIPT #  



(ATTACH COPY OF RABIES VACCINATIONS)




I ACKNOWLEDGE THAT BY SIGNING THIS REGISTRATION FORM, I HAVE BEEN GIVEN A COPY OF THE CITY OF BUCKNER’S ANIMAL ORDINANCES. I ACCEPT THE TERMS AND CONDITIONS  AND AGREE TO ABIDE BY THE CITY OF BUCKNER’S ANIMAL ORDINANCES. (EACH OWNER MUST SIGN).



SIGNATURE (S):  

SIGNATURE (S):  


ADMINISTRATION NOTES: