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2. First Name*
3. Last Name*
5. Phone Number*
7. Address*
9. City*
10. State*
11. Zip code*
13. How many dogs are you applying for today?*
    -- Select One --1234
17. Dog Name*
18. Breed*
20. Gender*

    1. Male
    2. Female
21. Altered (Spay/Neuter)*

    1. Yes
    2. No
22. Rabies Vaccination Expiration Date*
    Rabies Vaccination Expiration Date
24. Veterinarian Clinic*
28. Dog Name
29. Breed
31. Gender

    1. Male
    2. Female
32. Altered (Spay/Neuter)

    1. Yes
    2. No
33. Rabies Vaccination Expiration Date
    Rabies Vaccination Expiration Date
35. Veterinarian Clinic
39. Dog Name
40. Breed
42. Gender

    1. Male
    2. Female
43. Altered (Spay/Neuter)

    1. Yes
    2. No
44. Rabies Vaccination Expiration Date
    Rabies Vaccination Expiration Date
46. Veterinarian Clinic
50. Dog Name
51. Breed
53. Gender

    1. Male
    2. Female
54. Altered (Spay/Neuter)

    1. Yes
    2. No
55. Rabies Vaccination Expiration Date
    Rabies Vaccination Expiration Date
57. Veterinarian Clinic
61. Upload Proof of Rabies Vaccine
63. Proof of Rabies vaccination must be received within 5 days of payment. Failure to do so will result in your payment being forfeited and no license will be issued.

    For your convenience, there are several submission options available:

    • Mail or in-person: 118 W Maple, Centralia, WA 98531
    • Fax: 360-807-6210
    • Email Police Records
    • Upload online above

    1. I agree to provide proof of rabies within 5 days
Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit

* indicates a required field