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2. First Name
3. Last Name
5. Address1
7. City
8. State
9. Zip
11. Email
12. Primary Phone
16. Pet Name
17. Breed
18. License Number
22. Reason for Error

    1. Pet is currently license with the license number referenced above
    2. No longer own pet
    3. Pet is deceased
    4. No longer resident of the City of Rogers
    5. Other
24. Other Explanation
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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

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