New Jersey Department of Health

Infectious and Zoonotic Diseases Program

PO Box 369

Trenton, New Jersey 08625-0369

MONTHLY DOG LICENSE REPORT	FOR STATE USE ONLY
Check No.___________	Amount___________

Date of Check	________________________

Trans. Number	________________________

Date of Trans.	_________________________
A. IDENTIFICATION
Reporting Municipality

County

Date of Report

B. LICENSE DATA
Include ALL license numbers, not just those for which fees are being submitted.
1.	Period covered from	to
2.	First license number this report.
3.	Last license number this report.
4.	Last license number last report this year.
5.	Total licenses issued this report (subtract No. 4 from No. 3).
C. LICENSES ISSUED FOR WHICH NO MONEY IS SUBMITTED

List individually all licenses issued for which no fee is submitted. (Use additional sheets if necessary.)
#	License Number	Reason	#	License Number	Reason
1.	6.
2.	7.
3.	8.
4.	9.
5.	10.
D. PILOT CLINIC FUND	E. ANIMAL POPULATION CONTROL FUND
Surcharge (20 cents) for all licenses issued except for seeing eye, hearing ear and service dogs:	Additional surcharge ($3) for licenses issued for non-spayed and non-neutered dogs except for seeing eye, hearing ear and service dogs:
Number	Amount $
Number	Amount $
F. FEE DATA
1. Total amount due for registration fee ($1.00 for every license issued except for seeing eye, hearing ear and service dogs licensed without charge)	$
2. Total amount due for Pilot Clinic Fund (Section D)	$
3. Total amount due for Animal Population Control Fund (Section E)	$
4. Total amount due this report	$
G. CERTIFICATION
I certify that this report is a true and complete statement of dog licenses issued during the period indicated above.
Name (Print or Type)

Title

Signature	Date	Daytime Telephone Number

VPH-10

JUL 12	Distribution: Original to NJDOH, IZDP

VPH-10, Monthly Dog License Report

VPH-10, monthly dog license report, rabies, dog licensing, zoonotic, IZDP

ewhite

2001-05-25

NJDOH