Dog Registration

1. OWNER DETAILS

2. Your Name*
3. Residential Address*
4. Postal Address
5. Telephone*
6. Email
7. Pensioner* Yes - Concession available on 3 Year Registration only No

8. DETAILS OF DOG

9. Name*
10. Sex* Male Female
11. Sterilised* Yes No
12. Breed*
13. Colour / Markings*
14. Premises where the dog will ordinarily be kept*

15. FEES

16. Unsterilised Dog Please select... 1 Year - $30.00 3 Year - $75.00 Pensioner Discount 3 Year - $37.50 Working Dog 1 Year - $7.50 Working Dog 3 Year - $18.75
17. Sterilised Dog Please select... 1 Year - $10.00 3 Year - $18.00 Pensioner Discount 3 Year - $9.00 Working Dog 1 Year - $2.50 Working Dog 3 Year - $4.50
18. Payment of Fees* Pay by credit card over the phone - we will call you when your registration form has been submitted Credit card details submitted below

    Payment of your dog registration fees can be made by credit card over the phone on 98351022, or by submitting your credit card details below.

19. Credit Card Payment

    Complete details below if you wish to make payment by credit card with this submission.

20. Amount of Payment
21. Type of Card Master CardVisa Card
22. Name on Card
23. Card Number
24. Expiry Date
25. DECLARATION*
    I declare that I am over the age of eighteen (18) years, the particulars shown in this application are true to the best of my knowledge and belief, and I certify for the purpose of Section 16(1) of the Act, that means exist on the premises at which the dog will ordinarily be kept for effectively confining the dog within those premises. I agree
26. DATE SUBMITTED*

    Provide the date you are submitting this form.

* denotes a required field.