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2. Note: If you would prefer to fill out a hard copy application instead of the online form please click here.
4. Owner:*
5. Phone:*
7. Address:*
8. ZIP:*
9. Email:*
11. Location where animal(s) will be kept:*
13. PLEASE LIST BELOW ALL EXOTIC AND DANGEROUS ANIMALS OWNED BY YOU
15. # Exotic & Dangerous Animals owned*
    -- Select One --12345678910
17. Species:
18. Sex:
19. Color:
20. Weight:
22. Age:
23. Name:
24. Identification:
    (microchip, tattoo)
26. Species:
27. Sex:
28. Color:
29. Weight:
31. Age:
32. Name:
33. Identification:
    (microchip, tattoo)
35. Species:
36. Sex:
37. Color:
38. Weight:
40. Age:
41. Name:
42. Identification:
    (microchip, tattoo)
44. Species:
45. Sex:
46. Color:
47. Weight:
49. Age:
50. Name:
51. Identification:
    (microchip, tattoo)
53. Species:
54. Sex:
55. Color:
56. Weight:
58. Age:
59. Name:
60. Identification:
    (microchip, tattoo)
62. Species:
63. Sex:
64. Color:
65. Weight:
67. Age:
68. Name:
69. Identification:
    (microchip, tattoo)
71. Species:
72. Sex:
73. Color:
74. Weight:
76. Age:
77. Name:
78. Identification:
    (microchip, tattoo)
80. Species:
81. Sex:
82. Color:
83. Weight:
85. Age:
86. Name:
87. Identification:
    (microchip, tattoo)
89. Species:
90. Sex:
91. Color:
92. Weight:
94. Age:
95. Name:
96. Identification:
    (microchip, tattoo)
98. Species:
99. Sex:
100. Color:
101. Weight:
103. Age:
104. Name:
105. Identification:
     (microchip, tattoo)
107. Must File Proof of Insurance Acknowledgement*

     I understand that I must file with the Animal Services Director proof of ability to respond to damages in the form of a certificate of insurance from an insurance company authorized to do business in the state of North Carolina, stating that I am insured by a policy with a minimum coverage of one hundred thousand dollars ($100,000) per claim to compensate persons for personal injury and property damage. Such insurance shall provide that no cancellation of the insurance will be made unless ten (10) days written notice is first given to the Animal Services Director.

     1. I understand.
109. I also understand that this permit is not transferable.*

     1. I understand.
111. I have read and reviewed Part VI of the Pitt County Comprehensive Animal Services Ordinance.*

     1. I reviewed.
113. Electronic Signature Agreement*

     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.
115. Electronic Signature*
116. Date*
     Date
120. Section below is to be completed by Animal Services
122. Animal Services Signature:
123. Date:
Leave This Blank:


125. 1. Receive an email copy of this form.
126. Email address

     This field is not part of the form submission.

127. Submit Submit and Print

* indicates a required field