Town of Burlington

29 Center Street Phone (781)270-1660

Burlington, MA 01803 FAX (781)270-1608

Office of the Town Clerk Email: clerk@burlmass.org

Jane L. Chew, CMC Eleanor M. Gelinas, CMC

Town Clerk Assistant Town Clerk

MAIL-IN DOG LICENSE REQUEST

Please make checks payable to : TOWN OF BURLINGTON and send to:

Town Clerk

29 Center Street

Burlington, MA 01803

Your cancelled check will be your receipt. You may mail in this form, drop it at the Town Hall mailbox at the front stairs, or come into this office.

Dogs licensed after May 31st are subject to a $10 late licensing fee. Dogs unlicensed July lst are subject to a $50 fine. If you no longer have a dog, please notify this office and we will adjust our records. Please fill out the section below and include a rabies certificate.

You may renew your license for 1-3 years if the Rabies Expiration allows. Please check your preference, enclose a check for the correct amount and return this form.

1 YR.________ 2YRS.________ 3YRS.________

($15) ($20) ($25)

NAME:______________________________ PHONE___________________________

ADDRESS_____________________________________

DOG'S NAME___________________________ BREED______________________________

SEX_____ COLOR______________________ AGE___________________

RABIES EXPIRES:_____________________________(enclose certifcate)

Revision 1: 7/1/01