BIRTH DATE REQUIRED IF PURCHASING A SENIOR LICENSE (age 65). APPLICANTS FOR SENIOR OR
DISABILITY LICENSE MUST HAVE PROOF OF AGE OR DISABILITY ON FILE WITH THE COUNTY TREASURER.
I hereby verify that I am the owner of the described dog and all information provided on this
application is true and correct. I make this statement subject to the Criminal Penalties of
18 Pa. C.S. section 4904 (Relating to unsworn falsification to authorities.)
All fields are required. Licenses issued today expire on
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