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2. Date Declaration Notice Letter was Issued
   Date Declaration Notice Letter was Issued
3. Date of Application
   Date of Application
5. First Name*
6. Last Name*
8. Phone Number*
9. Alternate Phone
11. Address *
13. City
14. State
15. Zip
17. Is this the address where dog will be kept?*

    1. Yes
    2. No
19. Address where dog will be kept (if different that owner's address)
21. City
22. State
23. Zip
25. Name of Dog*
26. Age of Dog*
27. Sex of Dog*
    -- Select One --FemaleMaleFemale- SpayedMale- Neutered
29. Breed(s) of dog*
30. Color(s) of dog*
32. Is the dog microchipped?*

    1. Yes
    2. No
33. Microchip Number
35. Name of Veterinarian*
36. Veterinarian's phone number*
38. In accordance with North Carolina G.S. 67-4.1 your dog has been declared Potentially Dangerous or Dangerous and as such you must meet the requirements of state law for keeping a declared dog. Additionally, the City of Burlington Code of Ordinances Sec. 6-22 Dangerous Dogs or Potentially Dangerous Dogs stipulates declared dogs kept in the city are required to have a permit, be sterilized, microchipped, currently vaccinated against rabies, and kept securely and humanely confined. By typing my name below and submitting this form, I affirm the information I have provided is true and correct and that I understand and agree to comply with the provisions set for in NC G.S. 67 -4.1 -5 and City of Burlington Code of Ordinances Article III sec. 6-22. Attach a copy of current rabies vaccination certificate with this application and submit non-refundable application fee below.*
40. Attach copy or photo of most recent rabies vaccination certificate

    If you are unable to attach the rabies certificate here, you may email it to: animalcontrol@burlingtonnc.gov

42. Attach photo of dog here
44. Potentially Dangerous & Dangerous Dog Permit Application Fee
    Potentially Dangerous & Dangerous Dog Permit Application Fee
45. Price
47. Quantity
48. Shipping Cost
50. Taxable
Leave This Blank:


51. Calculate Totals Proceed to Checkout

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