Dog registration replacement registration tag application

1 Form ANL04 dog registration replacement tag #44158171 v9 21/11/2007 Page 1 of 2 Dog registration replacement registration tag application Animal Management (Cats and Dogs) Act 2008 Local Law No. 12 (Animal Management) 2013 Please use BLOCK LETTERS and complete all details in full. Council of the City of Gold Coast ABN 84 858 548 460 PO Box 5042 GCMC QLD 9729 P 07 5667 5987 W Applicant details Title Mr, Mrs, Miss, Ms, etc. Surname First name Middle name Postal address (if different to where dog is kept ) Email Business phone Home phone Mobile phone Family/friend name number Address where dog is kept Unit no Street number Complex/building name Street name Suburb Postcode Dog details Dog name Primary breed Microchip number Sex (F/M) Age Supporting information Please advise the reason a replacement tag is required Damaged Lost Stolen Other Form ANL04 dog registration replacement tag #44158171 v9 21//11/2017 Page 2 of 2 Privacy statement Council of the City of Gold Coast (Council)

2 Is collecting your personal information in order to provide the services requested, perform associated Council functions and services, and to update and maintain Council's customer information records. Your information is handled in accordance with the Information Privacy Act (Qld) 2009 and may only be accessed by Councillors, Council employees and authorised contractors. Unless authorised or required by law, we will not provide your personal information to any other person or agency. For further information go to Cityofgoldcoast/privacy Council may also use your personal information in order to contact you to provide you with information regarding Council functions and services. If you do not wish to receive such information please opt out using the unsubscribe link in the communication material sent to you.

3 Office use only Previous tag New tag Animal reference Dog name Date Customer Service officer Signature of applicant I understand and verify that: 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 (Animal Management) 2013 I approve the City to return my dog (if currently registered) to my property if found wandering for the first time, with an infringement notice being left I have a suitable enclosure or adequate fencing to prevent my dog(s) from escaping It is an offence to knowingly provide false or misleading information Approval of this application does not extend to the approval of any other statutory or local government requirements relating to this premises or activity Applicant Owner name Signature Date