Desexing and Microchipping Assistance Application

First Name *
Last Name *
Address *
City *
Post Code *
Home Phone
Cell Phone *
Email Address *
Dog's Name *
Dog's Age *
Dog's Sex *	Male Female
Dog's breed *
Desexed *	NoYes
Microchipped *	NoYes
Registered *	NoYes
Last Wormed *
If registered, what council?
Last Deflead *
Last Vaccinated *
Where does your dog sleep? *
Is your dog allowed inside? *	NoYes
How is your dog contained when it is outside on your property? *
Do you rent or own the property? *	Rent Own
If you rent do you have written permission to have the dog(s)	NoYes
Do you have a community services card? *	NoYes
What is your Community Services Card Number? You will need to bring your card with you if your application is approved. It will be scanned and put with your application.
Expiry date for Community Services Card
Income Source (include other household/family members) *
Where did you get your dog from? *
How long have you had your dog? *
Did you pay for your dog? *	NoYes
If yes, how much did you pay for your dog
How many dogs do you have? *
Please tell us about your other dogs. *
Do you have other pets? *
How does your dog behave in the car, meeting new people and at the vet? *
What assistance are you looking for today? Please note if you require food you need to complete the food assistance form. *	Desexing Food Microchipping
Why do you require assistance? *
Do you have transportation to go to the vet and/or collect food? *	NoYes
Do you have a regular vet? *	NoYes
Vet details if yes
When was the last time your dog went to the vet and why? *
When was your dog last on heat?
If your application is successful you will be required to contribute to the cost of the assistance. How much can you afford? *
What food does your dog normally eat?
How often do you feed your dog?
Does your dog have allergies?	NoYes
If your dog has allergies what are they?
How did you hear about the Dogwatch Community Outreach Programs?
Do you have any other comments to add?