11 Feb 2017 - Broken Hill City Council is collecting personal information you supply on this form in accordance with. Pr
Responsible pet ownership program 2017 Office Use Only Application Approved:
Yes ☐
Office Hours: 8.30am – 5pm 240 Blende Street PO Box 448 Broken Hill NSW 2880
[email protected] www.brokenhill.nsw.gov.au General Enquiries Phone: 08 8080 3300
No ☐
Approved By: ________________________________________ Booking Information: Date: ____/___/________
Time: _______________
Receipt Number: ____________________________________________________
Applications open Saturday, 11 February 2017 and close Friday, 3 March 2017 IMPORTANT NOTICE Broken Hill City Council is collecting personal information you supply on this form in accordance with Privacy and Personal Information Protection Act 1998. Your personal information will be accessed by persons who have been authorised to do so. Your information will not be given to any other person or agency unless required by law. Your personal information is handled in accordance with the Privacy and Personal Information Protection Act 1998. PART 1 – APPLICANT DETAILS Name: Telephone: Address: Do you receive any Centrelink benefits?
Card Number:
Expiry Date:
Yes ☐
_______________________________________
__________________
No ☐
Type of benefit received:
__________________________________________________________________________
PART 2 – PET DETAILS Species:
Dog ☐
Cat ☐
Sex:
Male ☐
Female ☐
Age:
Name: Breed:
Colour:
Health Problems: Is your pet: Microchipped: Yes ☐ No ☐ Microchip Number:
_______________________________________
Registered: Yes ☐ No ☐
PART 3 – GENERAL INFORMATION How many un-desexed dogs do you own?
Male:
Female:
How many un-desexed cats do you own?
Male:
Female:
How many litters have your female pets had?
Dogs:
Cats:
Office of Local Government – Responsible Pet Ownership Grants Program
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PART 5 – OWNER CONSENT If my application is successful, I consent, as the legal owner of the animal listed in this application, to my animal being permanently surgically desexed, microchipped and vaccinated (dogs only). I agree to the terms and conditions listed in this application. I agree to make full payment of the lifetime registration fee to Council, within 30 days of the date of my animal’s appointment. Owner’s Signature:
______________________________________________
Date:
_______________________
CONDITIONS OF APPLICATION 1. Applicant must complete an application form for each individual pet. 2. The applicant must complete all questions and parts of the application form to be considered for the program. 3. The applicant must be a resident of Broken Hill and the animal must reside within the boundaries of the Broken Hill area. 4. The applicant’s pet must not be a working dog. 5. The applicant must be able and willing to pay the entire discounted registration fee for their animal at Council’s Customer Relations Counter in the Administrative Centre within 30 days of the date of their appointment ($22 for an applicant who is eligible for a pensioner concession; and $53 for an applicant not eligible for a pensioner concession). 6. The owner must ensure their animal is delivered to the RSPCA at the time and date nominated by Council. If the owner needs to cancel the appointment, they must inform Council immediately at the time they become aware of the need for cancellation. 7. The owner will forfeit their right to benefit from the program if they do not present their animal at the specified time and date nominated by Council. 8. If the RSPCA believe there is reason to refuse an animal for health reasons, the applicant will be contacted to collect their animal without having received the service. The owner will not be eligible for any compensation in this instance. 9. In the case an animal is already registered, the owner is not eligible for a rebate on the registration fee once the animal is desexed. 10. If any of the information provided to Council and/or the RSPCA is found to be incorrect or misleading, the owner may forfeit their right to participate in the program and will not be eligible for any compensation. 11. The owner must acknowledge understanding of and sign the RSPCA permission form. 12. If successful, the applicant must complete a permanent identification form and lifetime registration form for each animal participating in the program.
Office of Local Government – Responsible Pet Ownership Grants Program
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