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2. Name of Applicant
3. Date
   Date
5. Home Address
7. City
8. Zip Code
10. Home Phone Number
12. Business Name
13. Business Phone Number
15. Business Address
17. City
18. Zip Code
22. Emergency Contact Name
23. Phone
25. Additional Phone
27. Address
31. Type of Permit

    1. New Permit
    2. Renewal Permit
32. Number of Days
33. Time Frame
    Time Frame Start Date

    —

    Time Frame End Date
35. Permit (Check All That Apply)

    1. Animal Acts / Exhibits
    2. Boarding Kennel
    3. Cat Breeder
    4. Cat Group
    5. Cat Show
    6. Circus
    7. Commercial Kennel

    1. Dog Breeder
    2. Dog Group
    3. Dog Show
    4. Pet Shop
    5. Motion Picture, Television or Theatrical Performance
    6. Restricted Animal
    7. Rodeo
39. Type of Animal
40. Number
42. Type of Animal
43. Number
45. Type of Animal
46. Number
48. Type of Animal
49. Number
51. Animals Kept At

    1. Business
    2. Home
    3. Other
53. Name of Rental Agency
    If animals are rented, please provide the name.
54. Rental Agency Phone
56. Rental Agency Address
60. Electronic Signature*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I Agree
    2. I Do Not Agree
62. Agreement
    I hereby agree to abide by the laws and the rules and regulations of the Division of Animal Services. I certify that all statements made on or in connections with the application are true and complete to the best of my knowledge and belief, and I understand and agree that any violation of Iowa City ordinances pertaining to animals, Iowa State Code Sections 717A or 717B, or Iowa City Animal Services rules and regulations relating to permits may be cause for denial or revocation of permit.
    
    I further understand and agree that my premises may be inspected in accordance with Section 8-4-2, City Code and such other sections as may be applicable.
64. Electronic Signature
65. Date
    Date

    Date
69. Division of Animal Services Report & Recommendation
71. Meets Requirements

    Applicant(s) meets, requirements set forth in the City Code and Iowa City Animal Services rules and regulations, and I therefore recommend this Permit.

    1. Be Granted
    2. Director Inspection Recommended
73. Does Not Meet Requirements

    Applicant(s) does not meet, requirements set forth in the City Code and Iowa City Animal Services rules and regulations, and I therefore recommend this Permit:

    1. Be Denied
    2. Director Inspection Recommended
75. Inspection Date
    Inspection Date
76. Inspected By
78. Permit Fee
79. Director Approval
81. Delinquent Fee
82. Date Granted
    Date Granted
84. Total Fees
85. Permit Number
86. Expires
    Expires
88. Receipt Number
89. City Zoning Approved
91. Notes
Leave This Blank:


93. 1. Receive an email copy of this form.
94. Email address

    This field is not part of the form submission.

95. Submit

* indicates a required field