2. Instructions
   Complete and submit the form below to request a replacement chicken leg band. All chickens are required to wear numbered leg bands for identification purposes. Replacement leg bands may be purchased separately if: 1) a band is lost or damaged, or 2) a chicken is sold or deceased. Residents may keep a maximum of six chickens and six leg bands. Leg bands cost $5 per chicken.
3. 
7. Contact Information
9. First Name*
10. Last Name*
12. Mailing Address*
14. City*
15. State*
16. Zip*
18. Phone Number*
22. Chicken Information
24. Chicken Permit Number*
25. Number of replacement bands needed*
    -- Select One --1 for $5.002 for $10.003 for $15.004 for $20.005 for $25.006 for $30.00
27. Old Leg Band Number(s)*
28. Reason for Replacement*

    1. Lost
    2. Damaged
    3. Sold
    4. Deceased
32. Next Steps
    Submit payment by check or money order. Payable to Coralville Police Department. Mail payment to:
34. Attn: Chicken Permits, Coralville Police Department, PO Box 5911, Coralville, IA 52241
36. *Leg bands will be mailed within 1-2 business days after the payment is received.
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38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

* indicates a required field