Form Center

2. 
4. Employee Name*
5. Email Address*
7. Department*
9. Phone Number*
11. Name of Dog*
12. Breed of Dog*

    If unknown, type All-American Dog.

14. Age of Dog, If known
15. List some fun traits about your dog. *
17. Is Your Dog a Rescue? *

    Type yes or no. 

18. Upload a Photo of Your Pet *
19. Upload photo #2
21. You may enter up to 3 pets, however you must submit a form for each one.
23. 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. 

    You agree to have your pet's likeness used to promote the Campbell County Treasurer's Office Life Time Dog Tag Campaign in print media, electronic media, and social media. You agree to save harmless Campbell County and its agents from any subsequent actions or outcomes that may occur by participating in this promotion. You agree and confirm that your pet is healthy, current on vaccinations and poses no threat to any Campbell County agent who may encounter it in the process of this promotion. 

    1. I agree.
25. Electronic Signature
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field