Equestrian Queensland Biosecurity Horse Health Declaration
Event Name:
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Arrival Date:
*
Departure Date:
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Are the horses/livestock listed below staying onsite for the duration of the event?
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Yes
No
If not staying onsite, are the horses/livestock returning each day to the PIC listed below?
Yes
No
Competitor's Name:
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Owner/person in charge of horses/livestock
*
Home Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone (Mobile):
*
Email:
*
Full address of origin of horses/livestock (if different from above):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PIC Number (Property Identification Code):
*
Are you crossing any tick lines to attend this event?
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Yes
No
If yes, what measures have you taken to ensure ticks are not carried across these lines?
Are you bringing any livestock other than horses to this event?
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No
Yes (please specify what type of livestock and complete all details below)
Horse 1 Registered Name:
*
Horse 1 Description/Sex
*
Horse 1 Microchip/Brand
*
PIC of property horse/livestock is returning to (if different from above):
Horse 1 Current Hendra Vaccination? Yes/No
*
Horse/Livestock 2 Registered Name:
Horse 2 Description/Sex
Horse 2 Microchip/Brand
Horse 2 PIC of property horse/livestock is returning to (if different from above):
Horse 2 Current Hendra Vaccination? Yes/No
Horse/Livestock 3 Registered Name:
Horse 3 Description/Sex
Horse 3 Microchip/Brand
PIC of property horse/livestock is returning to (if different from above):
Horse 3 Current Hendra Vaccination? Yes/No
Horse/Livestock 4 Details (Name, Description, Microchip, Brand, Hendra Vax):
Horse/Livestock 5 Details (Name, Description, Microchip, Brand, Hendra Vax):
Horse/Livestock 6 Details (Name, Description, Microchip, Brand, Hendra Vax):
Horse/Livestock 7 Details (Name, Description, Microchip, Brand, Hendra Vax):
I AGREE TO ENSURE THAT: (1.) All horses/livestock, vehicles and equipment accompanying horses/livestock will be clean and free of solid material (that could contain disease agents) prior to departing property of origin. I FURTHER DECLARE THAT: (2.) The information contained in this Biosecurity Declaration is true and correct to the best of my knowledge. (3.) I agree to abide and those people that are assisting me on the day, by all conditions that may be imposed at any time by the Event Organising Committee/Biosecurity Manager. (4.) I acknowledge that in failure to comply, or those people that are assisting me on the day fail to comply, may be directed to leave the event and my nominations will be forfeited. (5.) I acknowledge that decontamination and disinfection procedures may be required of me if instructed by the Event Organising Committee/ Biosecurity Manager. (6.) I acknowledge that there is a possibility that horses/livestock might become infected with disease agents as a result of any movements and if necessary, horses/livestock and premises will be quarantined in accordance with any legislation covering such occurrences including policies and procedures in effect at that time. (7.) I agree and acknowledge that the Biosecurity Manager/Event Organising Committee, its State or National Affiliated bodies and their members are not in any way liable for any cost, expense, loss, damage, claim, action, proceeding or other liability incurred by or made against me as a result of any movement of horses/livestock to the event/farm.
Yes
I agree to the above declaration
*
Yes
Name:
*
First Name
Last Name
Signature
*
Date:
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Continue
Continue
Should be Empty: