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PLC:7223
Agency:Henry County Treasurer
For:ANIMAL CONTROL FEES
Phone:309-937-2266

Address:119 S East Road
Box 153
Cambridge, Illinois 61238

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*Required Fields
*Clinic Name:
*Vaccination Date: (mm/dd/yyyy)
Vaccination Date.: (mm/dd/yyyy)
Vaccination Date..: (mm/dd/yyyy)
*Re-vaccination date: (mm/dd/yyyy)
Re-vaccination date.: (mm/dd/yyyy)
Re-vaccination date..: (mm/dd/yyyy)

*Registration Options:

Registration Options.:

Registration Options..:

*Breed:
Breed..:
Breed...:
*Name of Pet:
Name of Pet.:
Name of Pet..:
*Age:
Age.:
Age..:

*Sex:

Sex.:

Sex..:

*Pet Owner's Name:
*Phone #:
Phone #.:
Comments:

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