PO BOX 1136, MT OMMANEY QLD 4074 PHONE (07) 3252 2661, FAX (07) 3252 3864 Email: [email protected], Website: www.dogsqueensland.org.au

APPLICATION FOR REGISTRATION IN THE ASSOCIATE REGISTER AS AN ELIGIBLE MIXED BREED APPROVED FOR HERDING

This Application will ONLY be accepted if: (1) You are a current member of the CCC(Q) Ltd or an Application for Membership with appropriate fees are attached, (2) The dog concerned is currently in the CCC(Q) Ltd Associate Register or an Application for Registration in the Associate Register with appropriate fees, Original Certificate of Registration and Pedigree and Certificate of De-sexing are attached and (3) The dog’s microchip number is provided below. Current Associate Register fees are $20.00.

Name of Dog: ………………………………………………………………………………………………………

Associate Registration Number: .……………………………………..

Microchip Number of Dog: .………………………………………………………………………

Breed of Dam: ……………………………………… Breed of Sire: …………………………………………….

Name of Registered Owner(s): ……………………………………………………………………………………

Address: ……………………………………………………………………………………………………………..

………………………………………………………………………………Post Code: …………………………..

Owner(s) Membership No: ………………………………………. Contact Phone No: …………………….....

All Owners must sign – the ownership of the dog should be in exactly the same name as the Membership.

Signature(s): …………………………………………………………… Date: ……… / ……… / 20…………….

Signature(s): …………………………………………………………… Date: ……… / ……… / 20…………….

Instinct Safety Tested Name of Tester: …………………………………………………………………………………………………….

Address of Tester: ………………………………………………………………………………………………….

…………………………………………………………………………………… Post Code: …………………….

Contact Phone Number: ……………………………………

I hereby certify that I have “Instinct Safety Tested” the above-mentioned dog and in my opinion this dog can be considered for inclusion in the Associate Register for Herding.

Signature of Tester: …………………………………………………… Date: ……… / ……… / 20…………….

Herding Registration No.

OFFICE USE ONLY

\\SERVER-DOGSQLD\Data\Records & Forms\Dogs Qld Forms\ 2018 forms - updated Sep18\Herding Register Application.docx DOGS QUEENSLAND PO BOX 1136, MT OMMANEY QLD 4074 PHONE (07) 3252 2661, FAX (07) 3252 3864 Email: [email protected], Website: www.dogsqueensland.org.au

Breeds eligible for Herding Program:

ANKC Group 5 Other Herding Breeds Bernese Mountain Dog Canaan Dog Kerry Blue Terrier Soft Coated Wheaten Terrier Australian Stumpy Tail Cattle Dog Standard Schnauzer Bearded Giant Schnauzer

Belgian Shepherd Dogs [All Varieties] MIXED BREEDS Mixed breeds may be accepted, provided they are a mix or apparent mix of herding breeds. These must be Associate Bouvier des Flanders Registered Dogs.

Collie Rough and Smooth

German Shepherd Dog

Finnish Lapphund

Norwegian Buhund

Old English Sheepdog Puli Pumi Pembroke

\\SERVER-DOGSQLD\Data\Records & Forms\Dogs Qld Forms\ 2018 forms - updated Sep18\Herding Register Application.docx DOGS QUEENSLAND PO BOX 1136, MT OMMANEY QLD 4074 PHONE (07) 3252 2661, FAX (07) 3252 3864 Email: [email protected], Website: www.dogsqueensland.org.au

CREDIT CARD PAYMENT DETAILS

NAME: ______

MASTERCARD VISA (tick one box)

CARD NUMBER: ______- ______- ______- ______EXPIRY: __ - __

AMOUNT $______CARDHOLDER’S PHONE NUMBER: ______

CARDHOLDER SIGNATURE Date _____ / _____ / 20___

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