Application for name and address of
registered owner of dog
Please read this first
This form will be scanned by electronic equipment. It is important that you:
• use a blue or black pen to complete this form; and
• print clearly.
Office use only
Means of identication of applicant produced to the Tararua District Council
Application accepted Application declined
NAR Date
/ /
tararua district council
•
26 gordon street
•
po box 115
•
dannevirke 4942
•
06 374 4080
•
info@tararuadc.govt.nz
Details of dog
Registration number on collar, label, or disc (if known) Colour of dog
Breed / cross (if known)
Other identifying particulars
Address where dog is ordinarily kept / location where dog encountered
Applicant details (Please print in CAPITALS)
You are required to provide your name, address, and the purpose for which you require the information because Section 35 of
the Dog Control Act 1996 prohibits a territorial authority from supplying the information unless it is satised of the identity of the
applicant and that the information is required for one of a limited number of purposes specied in that section. The territorial
authority may keep a record of your application.
Title: Mr Mrs Miss Ms
First names
Surname
Postal address
Town Postcode
