Microchip exemption declaration

Microchip exemption declaration
Note: The Dog Control Act 1996, section 19A(2) states that failure to supply information or willfully providing false particulars about a dog can result in an infringement of $750.
I, First name* Last name* , Person ID* of Street address* City* Postcode* do solemnly declare that the dog(s) I currently own are used as working dogs, making them exempt from microchipping according to section 36A(2a) of the Dog Control Act 1996.
Dog name *
Dog ID/SR *
Dog 2 name
Dog 2 ID/SR
Dog 3 name
Dog 3 ID/SR
Dog 4 name
Dog 4 ID/SR
Name (dog owner) *

First name Last name
Date *

Day Month Year
Date
Name (dog control officer)

First Name Last Name
Date

Day Month Year
Date
Should be Empty: