Application for Special Licence
Section 138, Sale and Supply of Alcohol Act 2012
(Form 6)
Application to Register Dog(s)
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
Surname
Postal Address
Property Location
(if different from above)
Phone (home) MobilePhone (work)
Contact Numbers
Email
1. Owner* Details
Forenames
Owners Date of Birth
* For the purposes of the Dog Control Act 1996, you are the owner of a dog if -
• you own the dog; or
• you have the dog in your possession (otherwise than for a period not exceeding 72 hours for the purpose of preventing the dog causing injury, or
damage, or distress, or for the sole purpose of restoring a lost dog to its owner); or
• you are the parent or guardian of a person under the age of 16 who is the owner of the dog and who is a member of your household living with
and dependent on you.
2. Dog Details
Address where dog(s) is/are to be kept
Name of Dog
Age
Sex
Female
Male
Primary Breed
Primary Colour
Has the dog any distinguishing marks?
(If so, please describe)
Microchip Details (certicate required)
If Yes,
Council
Tag No
Is the dog de-sexed? (Certicate Required - Urban Only)
Is the dog currently registered with another Council?
Do you intend to keep more than two dogs on your property?
(Application for approval to keep more than two dogs is required for Urban properties only)
No
Yes
No
Yes
No
Yes
Secondary Breed
Secondary Colour
3. Owner Declaration
Failure to supply any of the information requested on this form may prevent the registration of your dog(s). You are encouraged to request
the Waitomo District Council to correct or amend any of these details if you discover a mistake or if the relevant circumstances change. You
are required to notify the Waitomo District Council of any change of address or change in ownership of the dog(s).
Signature of Applicant Date
4.OfceUse
Registration Fee
Rural Urban SOP Microchip Certicate De-sexing Certicate
Owner No.
Tag No’s Issued
Dog Control Act 1996, Section 36
If you have further dogs to register please use the space on the back of this form.
click to sign
signature
click to edit
Name of Dog
Age
Sex
Female
Male
Primary Breed
Primary Colour
Has the dog any distinguishing marks?
(If so, please describe)
Microchip Details (Certicate required)
If Yes,
Council
Tag No
Is the dog de-sexed? (Certicate Required - Urban Only)
Is the dog currently registered with another Council?
No
Yes
No
Yes
Secondary Breed
Secondary Colour
Name of Dog
Age
Sex
Female
Male
Primary Breed
Primary Colour
Has the dog any distinguishing marks?
(If so, please describe)
Microchip Details (Certicate required)
If Yes,
Council
Tag No
Is the dog de-sexed? (Certicate Required - Urban Only)
Is the dog currently registered with another Council?
No
Yes
No
Yes
Secondary Breed
Secondary Colour
If you have further dogs to register, please use the Dog Details Form and attach it to this form .
Dog Control Act 1996
Control of Dogs - Sections 52, 53 and 54A
The owner of a dog must keep the dog under control at all times and, when in a public place with the dog, must use or carry a leash at all
times. A dog will be treated as not being under control:
if it is found at large on any land or premises other than a public place or a private way without the consent (express or implied) of the
occupier or person in charge of the land or the premises; or
if it is found at large in any public place or in any private way in contravention of any regulations or bylaw.
You will commit an offence and be liable on conviction to a ne not exceeding $3,000 if you fail to comply with this provision.
Obligations of dog owner on owner’s property - Section 52A
The owner of a dog must ensure, when the dog is on land or premises occupied by the owner:
that the dog is under the direct control of a person; or
that the dog is conned within the land or premises in such a way that it cannot freely leave the land or premises.
You will commit an offence and be liable on conviction to a ne of $3,000 if you fail to comply with this provision. In addition, a dog control
ofcer or dog ranger may seize and impound the dog.
Obligations of dog owner generally - Section 54
The owner of a dog must:
ensure that the dog receives proper care and attention and is supplied with proper and sufcient food, water, and shelter; and
ensure that the dog receives adequate exercise.
You will commit an offence and be liable on conviction to imprisonment for up to 3 months or to a ne not exceeding $5,000 if you fail to
comply with this provision.
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