Municipality of Rhineland

Please fill out the following information.

A tag will be sent to you by mail. Please attach the tag to your dog's collar.

If you have any questions, please call our office at 204-324-5357 ext. 2 or send us an email. Thank you!

<form-template>
	<fields>
		<field type="header" subtype="h3" label="Owner Information" class="header"></field>
		<field type="text" subtype="text" required="true" label="Full Name" placeholder="First Name / Last Name" class="form-control text-input" name="text-1700587768011"></field>
		<field type="text" subtype="text" required="true" label="Street Address" placeholder="Street Address" class="form-control text-input" name="text-1700587995830"></field>
		<field type="text" subtype="text" required="true" label="Mailing Address" placeholder="Mailing Address" class="form-control text-input" name="text-1700594580629"></field>
		<field type="text" subtype="text" required="true" label="Town / City/ Province / Postal Code" placeholder="Town / City/ Province / Postal Code" class="form-control text-input" name="text-1700594659649"></field>
		<field type="text" subtype="text" required="true" label="Email Address" class="form-control text-input" name="text-1700588091351"></field>
		<field type="text" subtype="text" required="true" label="Phone Number" placeholder="(000) 000-0000" class="form-control text-input" name="text-1700588111377"></field>
		<field type="header" subtype="h3" label="Dog Information" class="header"></field>
		<field type="text" subtype="text" required="true" label="Dog's Name" placeholder="Very Good Dog" class="form-control text-input" name="text-1700589403103"></field>
		<field type="radio-group" required="true" label="Gender" class="radio-group" name="radio-group-1700594983055">
			<option value="Male Intact" selected="true">Male Intact</option>
			<option value="Male Neutered">Male Neutered</option>
			<option value="Female Intact">Female Intact</option>
			<option value="Female Spayed">Female Spayed</option>
		</field>
		<field type="text" subtype="text" required="true" label="Age / Year of Birth" class="form-control text-input" name="text-1700589540564"></field>
		<field type="text" subtype="text" required="true" label="Breed" class="form-control text-input" name="text-1700589611773"></field>
		<field type="radio-group" required="true" label="Current Rabies Vaccine?" class="radio-group" name="radio-group-1700595061492">
			<option value="Yes" selected="true">Yes</option>
			<option value="No">No</option>
		</field>
		<field type="text" subtype="text" required="true" label="Colour and Markings" class="form-control text-input" name="text-1700589629225"></field>
		<field type="text" subtype="text" required="true" label="Tattoo # (Enter N/A if Unknown)" class="form-control text-input" name="text-1700589668829"></field>
		<field type="checkbox" required="true" label="I authorize the Municipality of Rhineland to release this information to enable them to contact me if/when my dog is picked up or impounded" class="checkbox" name="checkbox-1700593310574"></field>
		<field type="text" subtype="text" required="true" label="E-Signature: Typing your name constitutes an electronic signature and all information provided above is correct." class="form-control text-input" name="text-1700593484674"></field>
		<field type="date" required="true" label="Date" class="form-control calendar" name="date-1700593514408"></field>
		<field type="file" required="true" label="Please upload the most recent photo of your dog!" class="form-control file-input" name="file-1700593538572" multiple="true"></field>
		<field type="radio-group" required="true" label="Dog Tag" class="radio-group" name="radio-group-1700595315085">
			<option value="Please mail me the tag" selected="true">Please mail me the tag</option>
			<option value="I will pick up my dog's tag at the Municipality of Rhineland's office">I will pick up my dog's tag at the Municipality of Rhineland's office</option>
		</field>
	</fields>
</form-template>

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Municipality of Rhineland

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