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4/27/23, 9:14 AM Upload Certificate of Insurance Choose File No file chosen Revize Online Forms RESIDENTIAL KENNEL ONLY: Name of Dog Breed Description MV License # Rabies Expiration Odin Red Heeler Brown with black nose, white spots on legs, short tail 01/30/2024 Format: MM/DD/YYYY Name of Dog Breed Description MV License # Phineas Corgi Tan with white stripe on forehead, two different colored eyes, white underside, long furry tail Rabies Expiration 02/04/2024 Format: MM/DD/YYYY Name of Dog Breed Description MV License # Rabies Expiration Poppy Jack Russel Terrier White with black spots, pink around lips, long tail 02/08/2024 Format: MM/DD/YYYY Name of Dog Breed Description MV License # Rabies Expiration M M/D D/YYYY Format: MM/DD/YYYY Upload Proof of Current Rabies Vaccinations (if records on file with the City are expired) Choose File No file chosen ALL APPLICANTS: * Have you ever had a license revoked? If yes, please explain. No Will an outside kennel or fence be constructed to house the dogs? If yes, a zoning permit is required. Zoning Permit Application CLICK HERE TENNESSEN WARNING/PRIVACY POLICY The data on this form will be used to approve your license. Some requested data is private. Private data is available to you and the City or State staff who need this information to perform their duties, but is not available to the public. You are being asked to answer questions and provide information pursuant to the application process that is required by Minnesota State Statute and the City of Mounds View. The information you provide is government data in accordance with Chapter 13 of State law known as the "Minnesota Government Data Practices Act". You are not required by law or ordinance to answer questions or provide the information requested. A refusal to answer questions or provide information being requested will prevent the City of Mounds View from processing the application for which you are applying. The information you provide may be classified as "public", "private" or "confidential" pursuant to the "Government Data Practices Act". Access to this information can be obtained by persons who are deemed eligible pursuant to the "act". This access can include the subject(s) of the license application, anyone they give their informed consent to consistent with Minnesota State law, or by court order. My signature constitutes agreement of the Tennessen Warning and application. https://moundsviewmn.rja.revize.com/reports/325713 2/3