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 identication 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
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 satised of the identity of the
applicant and that the information is required for one of a limited number of purposes specied in that section. The territorial
authority may keep a record of your application.
Title: Mr Mrs Miss Ms
First names
Postal address
Town Postcode
page 2 of 2 | application for name and address of registered owner of dog
Purpose information required for
The information is required by me for the purpose of (describe)
/ /
2 0
Signature of applicant Date
click to sign
click to edit