Fillable DOG ADOPTION APPLICATION FORM Please complete this form (Queenstown Lakes District Council New Zealand)

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DOG ADOPTION APPLICATION FORM Please complete this form (Queenstown Lakes District Council New Zealand)

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Country of origin: NEW-ZEALAND
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APPLICANT DETAILS
PROPERTY DETAILS
OTHER PETS
NAME Title (Mr, Mrs, Ms, Miss): First:
Middle: Surname:
ADDRESS
CONTACT Home: Work: Mobile:
Fax: Email:
PERSONAL Occupation: Date of Birth:
1. What best describes your current living situation?
House Flat/Apartment Farm/Lifestyle or rural property
2. If renting, do you have permission of your landlord to have a dog on the premises? Yes No
3. Name and contact phone number of landlord or agent:
4. Do you have any other pets? Yes No
If yes, please detail below:
If you currently own 2 dogs you will be required to obtain a permit from council to keep more than 2 dogs on your property.
SPECIES BREED AGE MALE/FEMALE
Page 1/3 // May 2015
DOG ADOPTION
APPLICATION FORM
Please complete this form
in full to apply to adopt a
puppy or dog from the
Animal Shelter.
This information in this form will be used to assist in the adoption of an
available dog and one this is suitable for you and your lifestyle.
Please send this form to
QUEENSTOWN LAKES DISTRICT COUNCIL
Private Bag 50072
QUEENSTOWN 9348
MANAGEMENT
WELFARE
5. Is there anyone home during the day to supervise the dog? Yes No
6. Where will the dog be housed?
7. Where will the dog be kept during the day?
8. Where will the dog be kept at night?
9. How will the dog be exercised?
10. Who will be responsible for exercising the dog?
11. Do you have children?
12. If so, what are the ages of the children?
13. What is the main reason for you getting a dog at this time?
14. Who is your regular veterinarian?
PREVIOUS OWNERSHIP
15. Have you ever owned a dog previously? Yes No
If yes, please detail below:
16. Do you have a Responsible Dog Owner status from your local council? Yes No
BREED DATES WHEN DOG OWNED ADDRESS WHERE DOG OWNED OTHER INFORMATION
Page 2/3 // May 2015
APPLICANT’S DECLARATION
ADOPTEES DISCLAIMER
I have answered the above questions
honestly. I give permission for a staff member of Queenstown Lakes District Council to visit my property to conduct a
property inspection and to conduct a follow up visit to my home after I have adopted a dog from the shelter.
Signed: Dated: / /
Dog Owners Name
Residential Address
Home Phone No
Mobile phone No
Work Phone No
Please read the following information and sign at the end of this document to indicate you have understood and accept the
terms and conditions of adoption from QLDC.
1. I agree to an Animal Control Officer visiting my property as a follow up visit to check on the success
of the adoption.
2. I accept that Queenstown Lakes District Council is not held responsible for any disease or illness that may
develop after leaving the care of Queenstown Lakes District Council.
3. I will ensure that the dog is loved and cared for and that I will be a responsible dog owner to ensure my dog is
not a nuisance to neighbours and to others.
4. Failure to comply with the above will result in the animal being uplifted by an Animal Control Officer and or
Animal Welfare Agency at their discretion.
Page 3/3 // May 2015
Queenstown Lakes District Council
Private Bag 50072, Queenstown 9348
Gorge Road, Queenstown 9300
P: 03 441 0499
E: services@qldc.govt.nz
www.qldc.govt.nz
THANK
YOU
FOR COMPLETING THIS FORM. THIS INFORMATION WILL HELP US
TO ADOPT A SUITABLE DOG FOR YOUR CIRCUMSTANCES. OUR AIM
IS TO ACHIEVE A HAPPY OUTCOME FOR THE DOG AND FOR YOU.
WE RESERVE THE RIGHT TO DECLINE THIS APPLICATION.
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DOG ADOPTION APPLICATION FORM Please complete this form (Queenstown Lakes District Council New Zealand)

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Completed 20 January 2021

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