Dog Registration Application Form Form No E6414-501 Lockyer Valley Regional Council, PO Box 82, Gatton Qld 4343 Version Draft 0.1 Phone: 1300 005 872 Email: mailbox@lvrc.qld.gov.au Page 1 of 2

Dog Registration Application FormAnimal Management (Cats and Dogs) Act 2008, Sections 46, 47 and 55 Please use blue or black pen and complete all details in full. * indicates a mandatory field

Applicant Details

*Title *Surname *Given Names

*Postal Address

*Suburb State Postcode

Home Phone Work Phone *Mobile

Fax Email Address

Dog Details

New Registration Change of Registration Information

Sex M/F *Age *Desexed *Breed *Colour *Microchip Number

Y N

Y N

Y N

Y N

Address where dog kept (if different from postal address)

Is your dog: A declared dangerous dog A declared menacing dog A restricted dog

Concessions

Desexing Concession Proof must be provided for each dog (Desexing Certificate or Statutory Declaration).

Reciprocal Registration Animal(s) currently registered in another Local Government area and relocated to LVRC. Proof must be provided (Registration Certificate from relevant Council).

Council Name Tag No(s) Expiry Date(s)

Previous Address

Pension Concession I am on a Pension (Age / 100% Disability / DVA Gold Card ONLY)

If Yes, please provide a copy of the card to Council at time of lodging this application. For 100% Disability ONLY, you are also required to provide Centrelink issued documentation (or mygov.com.au accessed and printed documents). OR

My Pension information confirming one of the above pensions has been previously provided to Council and is still current. I would like this Concession applied to my dog registration.

Dog Name

* Please note if proof is not supplied where the below concession/s apply,this application will not be accepted.

Dog Registration Application Form Form No E6414-501 Lockyer Valley Regional Council, PO Box 82, Gatton Qld 4343 Version Draft 0.1 Phone: 1300 005 872 Email: mailbox@lvrc.qld.gov.au Page 2 of 2

Declaration by Applicant I hereby apply for registration for the dog(s) listed in this application and declare that the details provided are true and correct to the best of my knowledge. • I acknowledge that the number of dogs kept at this property is in accordance with the allowable number of dogs to

be kept on a property this size as stated in Local Law No. 2 (Animal Management) 2011.• I am over the age of 18 years.• I have a suitable enclosure or adequate fencing to prevent my dog(s) from escaping.• I acknowledge that this registration is valid until 30 June only and thereafter every year the renewal period is

1 July – 30 June.

The Lockyer Valley Regional Council will not disclose your personal information to any other person or organisation, unless you have given us your consent to do so.

Tick this box to authorise Lockyer Valley Regional Council to serve dog registration renewal notices by electronic means (email). I acknowledge that by providing this consent the notices will not be served by post.

Tick this box to authorise the Lockyer Valley Regional Council to provide my home or mobile phone numbers to a third party when my dog is reported as being found.

Tick this box if the postal address provided in the Applicant Details section above is to be updated in our system for all correspondence from Council.

*Name of Applicant *Date

*Signature of Applicant

Privacy StatementThese details will only be used for the purpose for which they have been collected and will not be used for any other purpose. We will not disclose the information you provide outside of Council unless we are required by law or you have given your consent. To the fullest extent allowed by law, Council, its officers and employees will not be liable for any claims in respect of any loss arising out of, or in connection with, the use of any of the supplied information.

Office Use Only

Receipt of Proof of Pension Documents Yes No

Reciprocal Registration proof provided Yes No

Proof of desexing provided Yes No

CSO Name Microchip Flyer Provided

Animal ID Tag No Animal ID Tag No

Animal ID Tag No Animal ID Tag No