Application for Special Licence
Section 138, Sale and Supply of Alcohol Act 2012
(Form 6)
Application for Refund of
Dog Registration Fee
Queen Street, P O Box 404, Te Kuiti 3941, NZ. Telephone 07-878 0800, Fax 07-878 7771, Email enquiries@waitomo.govt.nz, Website www.waitomo.govt.nz
Owner Name
Postal Address
Property Location
(if different from above)
Phone (home) MobilePhone (work)
Contact Numbers
Email
Owner Signature
Date
1. Owner Details
Account Holder’s Name
Branch
Name of Bank
A printed bank deposit slip that matches the details of the applicant applying for the refund must be attached to this application.
Under the Dog Control Act 1996, the refundable amount of the fee is based on the number of complete months remaining in the registration
year after the date of the request for the refund.
2. Dog Details
Name of Dog
Date of Death
Tag Number
(Please attach registration tag)
4. Owner Declaration
I understand that making a false statemement in this application may make me liable upon conviction to a ne
not exceeding $3,000 under Section 41A of the Dog Control Act 1996.
5. Ofce Use
Owner No.
Refund Amount
3. Refund Details
Please refund the remaining portion of the current year’s registration to:
Rates Account Valuation Number
Direct Credit to my bank account
Date Actioned
NCS Record updated
Yes
No
Credited to rates
Refunded
Actioned by
Bank/Branch Bank Account Sufx
