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4. Petition for Removal of Obligation for Potentially Dangerous Animal (PDA) Permit
6. Case Report #
8. First Name
9. Last Name
11. Address1
13. City
14. State
15. Zip
17. Date of Birth
18. DL # and State
19. Phone Number 1
20. Phone Number 2
22. Address where animal currently resides (if different than above)
23. email address
25. Animal Information
27. Animal Name
28. Age
29. Sex

    1. M
    2. F
    3. NM*
    4. SF*
30. Type of Animal

    1. Dog
    2. Cat
    3. Other
33. * NM = Neutered Male, SF = Spayed Female
34. Other Type of Animal:
36. Breed
37. Color(s)
38. Markings
40. DocuPet License #
41. Microchip #
42. Rabies Tag #
44. Veterinary Clinic
45. Phone
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47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit Submit and Print

* indicates a required field