ACT Canine Association Inc. (ABN 11150955611) trading as Dogs A.C.T. Exhibition Park, Federal Highway, Mitchell, ACT. PO Box 815, Dickson ACT 2602. Email: admin@dogsact.org.au or visit: http://www.dogsact.org.au Office hours 9.30am to 2.30pm Tuesday to Thursday	Application to register an Associate Dog

Dog
Name:
Sex:	M / F
Date of birth:	(estimate if not known, mandatory)
Breed Combination:
(Eg. Collie/Labrador X)
Colour(s):
Any distinguishing features:
Desex/Sterilised Certificate:	Copy must be attached
Microchip Number:
Owner
Name
Address:
Suburb or Town:
Postcode:
Phone No:
Mobile:
Dogs ACT Membership No:
I certify that the above details are correct
Signature:
Date:
Credit card:	Mastercard ☐ Visa ☐ Debit card ☐
Cardholders Name:
Card Number:
Expiry date:	/
Card Verify Code:	(3 digit number on rear of card)
Fee to register an Associate Dog:	$
Office Use Only
Registration Number
Desex/Sterilised Certificate attached	……………………. (mandatory)
Microchip Number Confirmed	Yes / No