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2. First Name
3. Last Name
5. Phone Number
6. Email
8. Address1
10. Address2
12. City
13. State
14. Zip
16. Dog's Name
17. Date Filing
    Date Filing
19. Is this in regards to a dog bite?
    If yes, please provide the police, animal control or veterinarian contacted and official bite form file date and report number.
21. Please describe the issue you are having:
23. If there is another person or dog involved, please provide the human and dog's names:
25. Date of Incident
    Date of Incident
27. Preferred form of response?
    Email, phone, letter, etc.
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field