Privacy Statement Council is collecting this information in order to comply with its responsibilities and obligations as a Local Government. The information will only be used by Council Officers or Agencies which may have a legitimate need for the
information to process applications or the like. This information will not be disclosed to a third party unless you have given your written consent or we are required to do so by law. For more information about privacy in Central Highlands Regional
Council see our Privacy Plan on our website.
Central Highlands Regional Council – General Enquiries: 1300 242 686 Fax: 1300 242 687 Email: [email protected]
Application for Registration/Renewal of
Registration/Change of
Details of Registration of a Dog
Animal Management (Cats and
Dogs) Act 2008
REGISTRATION CERTIFICATE
(REGISTRATION PERIOD 1 July 2015 to 30 June 2016)
This application form becomes your registration certificate once paid.
Sections 46, 47, 54 and 55
Application
Date &
Type
__ __/__ __/__ _ New registration Renewal of registration Change of details
Applicant
Details
Full name
Date of Birth:
Residential address:
Suburb: State: Postcode:
Postal address:
As above
Suburb: State: Postcode:
Telephone:
Email:
Details of
Animal/s
If the dog is
desexed or
micro-chipped
a veterinary
surgeon’s
certificate must
be attached to
the application.
Animals must
be
microchipped if
born after 1
st
July 2009
(A) Name:
Breed:
Date of Birth:
Sex:
Date of Birth:
Sex:
Desexed: Yes No
Colour & Features:
Permanent Identification Number (PID) / Microchip:
(if applicable)
Address
(at which
the animal
is kept)
If different to above
If different to above
Regulated
Dogs only
Restricted Dog Dangerous Dog Menacing Permit number: ………………………………..
Declaration
I apply for the registration of the dog/cat described above and declare that the particulars are correct in
every detail and that I have read the Council’s terms and conditions on the back of this application form.
Applicant’s signature ………………………………………………………............. Date…………………….
Office Use Only (Receipt Code T23 New)
Tag No (A):
Tag No (B):
Receipt No:
Pensioner Card Sighted
Animal No (A):
Animal No (B):
Amount Paid:
Veterinary surgeon’s certificate attached
if cat/dog desexed or micro-chipped
Privacy Statement Council is collecting this information in order to comply with its responsibilities and obligations as a Local Government. The information will only be used by Council Officers or Agencies which may have a legitimate need for the
information to process applications or the like. This information will not be disclosed to a third party unless you have given your written consent or we are required to do so by law. For more information about privacy in Central Highlands Regional
Council see our Privacy Plan on our website.
Central Highlands Regional Council – General Enquiries: 1300 242 686 Fax: 1300 242 687 Email: [email protected]
Concessions
Pensioner (card
must be sighted)
Name of card holder:
Pension Number: Expiry date: ___/____
Type
Aged Widow Invalid
Assistance Dog?
(Proof must be
supplied)
Is the dog an assistance dog?
Yes No (NO CHARGE)
Type
Hearing Guide Dog
Terms and Conditions
1. I am aware that the number of animals kept at this property is in accordance with the allowable number of dogs to
be kept on a property this size as stated in Council’s local laws dealing with animals
2. I approve of Council returning my animal (if currently registered) to my property if found wandering for the first time.
3. I approve of Council releasing my details to a person or organisation who has found my animal for the purposes of
returning the animal.
4. I recognize that failure to comply with the Council’s Local Laws and any relevant provision of the Animal
Management (Cats and Dogs ) Act 2008 may result in the Council taking action against myself.
5. I have a suitable enclosure or adequate fencing to prevent my animals from escaping from my property. (The
keeping of dogs on a lead or runners is not a sufficient enclosure.)
6. I acknowledge that my animal/s must be walked on a chain, cord or leash by a person who is physically able to
control the animal.
7. I understand that my animal/s must wear the registration tag at all times. Should the tag become lost and/or
damaged, I must make application to Council for a replacement tag forthwith.
8. My dog is not of a breed defined under the Animal Management (Cats and Dogs) Act 2008 as a “restricted dog”.
9. The following breeds of dog are prohibited.
American Pit Bull Terrier, American Pit Bull Terrier types or cross breeds of an American Pit Bull Terrier
Dogo Argentino or cross breeds of a Dogo Argentino
Fila Brasileiro or cross breeds of a Fila Brasileiro
Japanese Tosa or cross breeds of a Japanese Tosa
Perro de Presa Canario or Presa Canario or cross breeds of a Perro de Presa Canario or Presa Canario