Your name

Your email

Your phone number

Your address

Object

Explain your permit application

Attach the necessary files to your request (e.g. sketches, plan, location certificate, photos, etc.)

Electronic signature certificate

By checking the box, you certify that the information provided in this document is true, accurate and complete and agree to sign this application electronically.

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Identification of the dog's owner or keeper

First Name

Last Name

Identification of the dog's owner or keeper (if more than one)

Name

Name

Address

Phone (residence)

Phone (mobile)

Phone (work)

Email address

Dog information

Breed of dog

Sex
MâleFemelle

Year of birth

Dog's name

Color and distinctive signs, if any

Origin of the dog (e.g. Township SPA, purchased from Mr. X in Cowansville or other indications)
Name and address

Weight equal to or greater than 20kg
OuiNon

Vaccinated against rabies
OuiNon

Last vaccination date

Name of veterinarian or clinic

Sterilized
OuiNon

Microchip
OuiNonIf so, microchip number:

Dog history

Do you have a written opinion from a veterinarian stating that vaccination, sterilization or microchipping is contraindated for your dog (special cases)
OuiNon

Name of municipalities where the dog has already been registered, if necessary

Has a decision ever been made by another local municipality with respect to the dog or its owner or keeper under this by-law or bylaw for dogs?
OuiNon If so, please specify:

The owner or custodian of a dog must inform the Municipality of the Village of Brome of any changes to the information provided in this form. If you dispose of the dog or die, it is your responsibility to notify the Municipality.

I declare that all the information contained is accurate and truthful.

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