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SWORN STATEMENT FOR SPAYED OR NEUTERED DOG

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  2. _________________

    Dog I.D number

  4. I,_________________________________________________
  6. I reside at _________________________________________and I am the owner of a dog described as follows:
  8. Breed: _____________________ Color __________________
  10. Age: ______ Sex: ______
  12. This dog was spayed/ neutered by Dr. ________________________________________
  14. Veterinarian Address___________________________________________________ On or about __________________

                                                Street                           City                               State                                           Date

  16. ____________________________________________

    Applicant Signature

    17. Leave This Blank: