1ST DOG
2ND DOG
DECLARATION
TOTAL FEES
Owner’s First name: Owner’s last name:
Owner’s Date of birth:
Address where dog is kept:
Postal address:
Phone: Alternative Phone number:
Email:
Is your property effectively fenced and cannot escape? YES NO
Has your dog received an infringement or impound in the last 24 months? YES NO
Number of dogs kept at property?
NEW TRANSFER From where: Tag Number:
Name of 1st dog: Breed:
Age of Dog: NZ Microchip Number:
Sex: M F Neutered: YES NO PET WORKING GUIDE
Primary colour: RED WHITE BLACK BROWN TRI BLUE GOLD GREY ORANGE BRINDLE
Secondary colour: RED WHITE BLACK BROWN TRI BLUE GOLD GREY ORANGE BRINDLE
Registration tag number: Fee:
NEW TRANSFER From where: Tag Number:
Name of 1st dog: Breed:
Age of Dog: NZ Microchip Number:
Sex: M F Neutered: YES NO PET WORKING GUIDE
Primary colour: RED WHITE BLACK BROWN TRI BLUE GOLD GREY ORANGE BRINDLE
Secondary colour: RED WHITE BLACK BROWN TRI BLUE GOLD GREY ORANGE BRINDLE
Registration tag number: Fee:
I DECLARE THAT ALL THE INFORMATION CONTAINED WITHIN THIS APPLICATION FORM IS CORRECT
Signed: Date:
Please be aware that all elds are mandatory, failure to complete the form will result in your dog/s being unregistered
Please note: it is an offence, when applying for the registration of a dog, to knowingly make any false written statements. This can incur an infringement of $750 or
conviction; the court may impose a ne of up to $3,000.
If your details change, it is your responsibility to ensure you contact us to update these details.
Please be aware that all elds are mandatory, failure to complete the form will result in your dog/s being unregistered
Total fees to be paid: $
(Owner’s date of birth is a legal requirement in the dog control act 1996)
(We do not accept mongrel)
(We do not accept mongrel)
(Issued by QLDC)
(Issued by QLDC)
(If there are more than two dogs on your property you will need to ll in an additional application form)
Page 1/1 // April 2016
DOG REGISTRATION
APPLICATION FORM
click to sign
signature
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