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POTENTIALLY DANGEROUS DOG <br /> REQUEST FOR HEARING <br /> (To be completed by Dog Owner) <br /> --- ___.__..__,------ <br /> _._._ � ..__....�___..__ ._ <br /> ---__-----__ ----- � <br /> ; Date of Request:_.� � � � , Dog s Name � ; <br /> , .,1 , �e' , � r <br /> � �—: ___. _ _.. -------- --- � . <br /> _.. .. . _._ ..__ <br /> _____. <br /> __.. <br /> _._ ___ . <br /> Owners Name;_. ,� . ? r pog's Description , . ,� � ' <br /> y . I <br /> f F `I"_' � � ' S�R'.� � ,�. � r .\� 'va �' x �v � ��1,p <br /> � t_ � , <br /> � - � ��. __' J --- �---- -�-_..:,.. ___ _�_._.� _.�...._ . Lt <br /> � Owner Address: —�Owner Telephone: �� <br /> ` ��, � �:� ��. �_._.._.Y�..�4. �- �. ':�����•`_ £ �{ � - 1 � � <br /> � ..�'.� � .� � � `. , ' Y � � �' ��_' 4 _ _____.�___.._. ._l <br /> >,�� � . ,: :� , �.�, ; �; � �� <br /> �� � .r <br /> • Request for hearing must be made within(14)days of receipt of notice of potentially dangeraus dog <br /> determination. <br /> ■ Hearing must be held within fourteen(14)days of receipt of this request. <br /> ■ The hearing officer shall issue a decision on the matter within ten(10)days after the hearing. <br /> ■ If a request is made the owner must still comply with the requirements of section 347.515 to have a microchip <br /> implanted within 14 days of receipt of the notice of potentialiy dangerous dog. <br /> I hereby request a hearing to determine the validity of the potentially dangerous dog declaration regarding said dog. <br /> 1 j�Y � C ,4� �! � ` ` M <br /> ' } <br /> (Signatare of Owner) <br /> FOR OFFICE USE ONLY: Received by: Date: � f� r� � ICR# ,��U O ���� <br /> Date of Service: <br />