Neutered Dog Declaration
If during the year your dog has been Neutered/speyed and you notify us you may be
eligible to a pro rata refund of your part of your registration fee (from date of notification).
Please complete this form and forward to Masterton District Council, Animal Services, P O
Box 444, Masterton 5840 or email: animalservices@mstn.govt.nz
OWNER DETAILS
Owner’s name:
MDC Owner No:
Owner Date of birth:
Street Address:
Email:
Home Phone:
Mobile Phone:
DOG DETAILS
Name:
Breed:
Tag Number:
Colour:
Age:
Sex:
Name:
Breed:
Tag Number:
Colour:
Age:
Sex:
VETERINARY CLINIC Please provide written confirmation from the vet if they have neutered/speyed your dog this
can be emailed by the vet clinic to animalservices@mstn.govt.nz Or they can complete the section below
Name of Veterinary Clinic:
On behalf of the above named Veterinary Practice I confirm that the dog/s listed above were desexed
by a member of our Veterinary practice:
Date of Desexing:
Signature
(Vet Clinic Staff member) with Clinic Stamp
DECLARATION
I hereby certify that I am the registered dog owner and the above information it true and correct.
(Please note we can impose a penalty for providing a false statement under the Dog Control Act 1996)
Signature of registered owner
Credit Dog Account
Credit Rates Account
Property Valuation Number:
Credit Bank Account Number
Please provide a bank deposit slip or printout from your bank. Hand written
account numbers must be written by owners and are provided at owner’s risk.
OFFICE USE ONLY
Refund required:
Yes No
GL: 9030202
Refund Amount:
$
Approved By:
Date Paid:
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