Animal Registration Form

Shire of Mundaring
Animal Registration Form

Animal *

 
Registration Type *

 
Previous Local Government

 
Previous Tag Number

 
Animal Reference Number

Prerequisites

Sterilised *

 
Microchipped *

 
Exemption Given By Vet?

 
Microchip Number (15 digits)


 
Please provide details of the exemption and issuing veterinarian.

Owner Details

Full Name *


 
Date of Birth *  (YYYY-MM-DD)

 
 
Email
Residential Address *

House Number *
Road  *
Suburb  *
     
Postal Address *

Same as residential 
 
Contact Number (Primary) *

 
Contact Number (Other)


Number of dogs at address *

 

Alternative Contact

Full Name *


 
Date of Birth *  (YYYY-MM-DD)

 
 
Residential Address *

Same as owner
House Number
Road 
Suburb and Postcode 
     
Contact Number (Primary) *

 
Contact Number (Other)


Previous Convictions

Have you had any convictions for offences against the Cat Act 2011, Dog Act 1976 or Animal Welfare Act 2002 in the past three years? *

 
Please give details specifying the date of conviction(s), nature of the offence and the legislation involved. *

 
Are you currently or have you ever been banned from owning or keeping a dog under the Dog Act 1976 section 46A(2) either permanently or for a period specified in the order? *

 
Please give details of the order. *

 

Animal Details

Name *

 
Age (if known)


Gender *


 
Colour (closest match) *


   
Breed *

  
Cross Breed


Any distinguishing marks or features?

Animal's Primary Residence *

Same as owner
House Number
Road 
Suburb 
     
Kept as commercial security dog? *

 
Is the dog a Pit Bull Terrier, American Pit Bull Terrier or a mix of these breeds? *

 
Decleared dangerous dog? *

 
Please provide details. *

 

Fees

Do you possess a:

 Pensioner Concession Card

 Veteran Affairs Card


Please select preferred renewal option. *



 

1 Year Renewal

3 Year Renewal

Lifetime Renewal

$ $ $
Amount Due: $ 

Attachments

No attachments are required.







   
 

Payment Options

Please select your preferred payment method.


Please provide your credit card details.

Your card will not be charged until your registration has been processed and approved. Upon successful payment, your tag and registration certificate will be mailed out to you.
NOTE: Your credit card details will be destroyed after processing.

Card Type
Card Number


Name on Card
Expiry Date
 / 
Amount to be charged: $

Declaration

By ticking the box below, I declare that:

  • I have read, understood and agree to the terms and conditions.
  • The information provided in this application is true and correct to the best of my knowledge.
  • I am aware it is an offence to provide false or misleading information.
  • I am aware that Shire of Mundaring may refuse an application if or all of the required information is not provided within the time period specified in the legislation.
 I Agree.*





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