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11/10/21, 1:51 PM <br />Revize Online Forms <br />Dog Kennel License Application <br />Submitted by: Paul Holt <br />Status: Open <br />M 0 t N b4s W <br />DOG KENNEL LICENSE APPLICATION <br />2401 Mounds View Blvd. I Mounds View, MN 55112 <br />(763) 717-4000 1 Fax (763) 717-4019 <br />info@moundsviewmn.org <br />* Applicant First Name MI * Applicant Last Name <br />Paul Holt <br />* Applicant Home Address <br />4315 Chatsworth Street North <br />City State Zip Code <br />Shoreview MN 55126 <br />* Email <br />holtsboardandtrain@gmail.com <br />Valid Email Required <br />Business Name (If Commercial) <br />Holt's Board & Train <br />* Phone <br />6512499603 <br />Phone 2 <br />Ex. (123) 456-7890 <br />❑ $45 Annually / Residential Kennel - 3 to 4 Dogs <br />a $80 Annually / Commercial Kennel - 5 or More Dogs (Tax Clearance and Workers Comp Form Required) <br />Tax Clearance/MN Workers Comp Form (Required if applying for a commercial license) <br />RESIDENTIAL KENNEL ONLY: <br />Name of Dog Breed <br />Name of Dog Breed <br />Name of Dog Breed <br />Description MV License # Rabies Expiration <br />M M/D D/YYYY <br />Description MV License # <br />Description MV License # <br />Format: MM/DD/YYYY <br />Rabies Expiration <br />M M/D D/YYYY <br />Format: MM/DD/YYYY <br />Rabies Expiration <br />M M/D D/YYYY <br />Apt/Unit <br />Format: MM/DD/YYYY <br />https://moundsviewmn.rja.revize.com/reports/179343 1/2 <br />