Schedule 1

Forms

In force

Form 1

[r. 14]

[Heading inserted: SL 2020/213 r. 13.]

Dog Act 1976 s. 11(3)

Certificate of authorisation

⁽¹⁾______________________________________________________

[Photograph of authorised person]

This is to certify that ⁽²⁾...............................................

has been appointed by the ⁽¹⁾.......................................

........................................ to exercise the powers of a registration officer in accordance with the provisions of the Dog Act 1976.

Signed ...................................................................
CEO of the ⁽¹⁾....................................

..................................................... ......................................
Signature of authorised person Date

Insert:

(1)

name of local government;

(2)

name of authorised person.

[Form 1 inserted: SL 2020/213 r. 13.]

Form 2

[r. 15]

Dog Act 1976 s. 12A(3) and 29(5a)

Application for warrant to enter and inspect premises or to seize and detain attack dog or pups of dangerous dog (restricted breed)

I, ⁽¹⁾ __________________________________________________________

of ⁽²⁾ __________________________________________________________

in the State of Western Australia, make oath and say as follows —

1. I am ⁽³⁾__________________________________ a police officer, ⊕

(4)

a ______________________________________ appointed by the

(5)

_______________________________________,⊕ and authorised

to exercise the powers mentioned in section(s) 12A(2) and/or 29⊕ of the Dog Act 1976.

2.⊕ I apply for a warrant to be issued under the Dog Act 1976 section 12A(3) to enter and inspect premises at _______________________________

________________________________________ ⁽⁸⁾for the purpose of

___________________________________ (relating to the enforcement of the Act). The grounds for seeking the warrant are ________________________________________________________

3.⊕ I apply for the issue of a warrant under the Dog Act 1976 section 29(5a) authorising the seizure and detention of a dog ⁽⁶⁾ __________________

that has attacked ⁽⁷⁾__________________________________

and that has or may have caused injury or damage. The premises to be

entered are at _____________________________________________ ⁽⁸⁾

The grounds for seeking the warrant are _________________________

4.⊕ I apply for the issue of a warrant under the Dog Act 1976 section 29(5a) authorising the seizure and detention of the pups of a dangerous dog (restricted breed) that may be the subject of an offence under the Dog Act 1976 section 33GD (breeding of dangerous dogs (restricted breed)).

The premises to be entered are at ____________________________ ⁽⁸⁾

The grounds for seeking the warrant are ________________________

		__________________________ Applicant’s signature
Sworn at this day of by the applicant before me		__________________________ J.P.

Insert:

(1)

name of applicant;

(2)

address of applicant;

(3)

number, rank or description;

(4)

description of employment (e.g. “ranger”);

(5)

name of local government;

(6)

description of dog;

(7)

name or description of person, animal or property attacked;

(8)

address or description of premises.

⊕ Delete if not appropriate.

[Form 2 amended: Gazette 20 May 2014 p. 1605.]

Form 3

[r. 15]

Dog Act 1976 s. 12A(3) and 29(5a)

Warrant to enter and inspect premises or to seize and detain attack dog or pups of dangerous dog (restricted breed)

I, a justice of the peace, being satisfied that there are reasonable grounds for doing so, issue this warrant under the Dog Act 1976 section 12A(3) for ________________ ⁽¹⁾, a person authorised to exercise powers mentioned in section 12A(2) and all police officers, to enter and inspect premises at ___________________________ ⁽²⁾ for the purpose of _______________________________________ (relating to the enforcement of the Act).

I, a justice of the peace, being satisfied that on the balance of probabilities that an attack by a dog ⁽³⁾___________has or may have caused injury or damage to _________⁽⁴⁾, issue this warrant under the Dog Act 1976 section 29(5a) for ________________ ⁽¹⁾, a person authorised to exercise powers mentioned in section 29(5a) and all police officers, to seize and detain the dog. By issuing this warrant the authorised person may, under the Dog Act 1976 section 29(5a)(b), enter any premises if the person has reasonable grounds to believe that it is necessary to do so for the purpose of seizing the dog.

I, a justice of the peace, being satisfied that on the balance of probabilities that a dangerous dog (restricted breed) has given birth to one or more pups, issue this warrant under the Dog Act 1976 section 29(5a) for ______________ ⁽¹⁾, a person authorised to exercise powers mentioned in section 29(5a) and all police officers, to seize and detain each pup. By issuing this warrant the authorised person may, under the Dog Act 1976 section 29(5b)(b), enter any premises if the person has reasonable grounds to believe that it is necessary to do so for the purpose of seizing the pups.

Signed _____________________________

Justice of the Peace

Dated ______________________________

Insert:

(1)

name of person to whom warrant is issued;

(2)

address or description of premises;

(3)

description of dog;

(4)

name or description of person attacked.

[Form 3 inserted: Gazette 11 Mar 2016 p. 689‑90.]

Form 4

[r. 20, 22 and 23]

Application/information form

Part A — Owner details

Dog owner’s full name ______________________________________

Residential address _________________________________________

_________________________________________

Postal address

(if different from above) __________________________________________

___________________________________________

Age (dd/mm/yy) _____/_____/_______

(owner must be 18 years or older)

Contact telephone number

(home, work, mobile) (H) ________________________

(W)

________________________

(M)

________________________

Email address (if available) ____________________________________

Can your local government use this email address to issue renewal notices and other relevant information?

Yes/No (delete one)

Owner’s delegate contact details (optional)

Name of alternative ________________________________________

Residential address ________________________________________

________________________________________

Postal address

(if different from above) _________________________________________

_________________________________________

Age (dd/mm/yy) _____/_____/_______

(must be 18 years or older)

Contact telephone number

(home, work, mobile) (H) ________________________

(W)

________________________

(M)

________________________

Part B — Dog details

Address where dog is normally kept

(if different from above) _________________________________________

_________________________________________

Number of dogs to be located at these premises ___________

Will the dog/s be effectively confined in or at the premises identified above?

Yes/No (delete one)

Dog details

Dog’s name ______________________________

Age (dd/mm/yy) _____/_____/_______

Breed (if known) __________________________

Colour __________________________

Gender __________________________

Microchip number __________________________

Microchip database company __________________________

Is the dog sterilised? Yes/No (delete one)

Any distinguishing features or marks?

______________________________________________________

Is the dog kept, or to be kept, as a commercial security dog?

Yes/No (delete one)

Has the dog been declared a dangerous dog?

Yes/No (delete one)

If yes, please provide details ___________________________________

__________________________________________________________

Is the dog a pit bull terrier, an American pit bull terrier or a mix of one or both of those breeds?

Yes/No/Unknown (delete two)

Is the dog kept for the purposes of the Crown?

Yes/No (delete one) (If yes, note that the Dog Act 1976 does not apply: section 6(4).)

Part C — Notification of new owner

New dog owner’s name _____________________________________

_____________________________________

New owner’s residential address ______________________________

______________________________________

New owner’s contact numbers

(home, work, mobile) (H)________________________

(W)

________________________

(M)

________________________

Part D — Registration

Application or renewal for —

• a period of 1 year (✓): ❒

• a period of 3 years (✓): ❒

Application for lifetime registration (✓): ❒

Prescribed fee for —

• a period of 1 year (✓): ❒

• a period of 3 years (✓): ❒

Prescribed lifetime fee (✓): ❒

Assistance dog (✓): ❒

Dog for droving or tending stock (✓): ❒

Are you eligible for a pensioner concession? ? Yes/No (delete one)

Previous local government where dog was registered (if known)

_________________________________________________________

Registration number (to be issued by local government) ____________________________________

Part E — Previous convictions, relevant orders

Do you have any convictions for offences against the Dog Act 1976, Cat Act 2011 or Animal Welfare Act 2002 in past 3 years?

Yes/No (delete one)

If yes, please give details, specifying the date of the conviction(s), nature of the offence and the legislation involved

________________________________________________________

Are you currently banned, or have you ever been banned, from owning or keeping a dog under an order under the Dog Act 1976 section 46A(2) either permanently or for a period specified in the order?

Yes/No (delete one)

If yes, please give details of the order

________________________________________________________

Part F — Declaration

The local government may refuse an application if any or all of the required information is not provided within the time period specified in the legislation.

I, ___________________________________________________________ (person’s full name or organisation/company name)

___________________________________________________________

of ___________________________________________________________

(address)

___________________________________________________________

__________________________________________________ _______ (postcode)

declare that the information I have provided is true and correct.

I am aware that it is an offence to provide false and misleading information.

Signature _____________________________________________

[A signature is not required to effect the form when the form is lodged through a local government website.]

[Local government details and logo here]

Payment options:

[Each local government is to detail their payment options here]

Further details required by local government

_______________________________________________________________

Part G — Local government use only

Registration approved (✓): ❒

• Assigned registration number ___________________

[Form 4 amended: Gazette 20 May 2014 p. 1605.]

Form 5

[r. 21]

Dog Act 1976 s. 16(6)(a)

Certificate of registration

This is to certify that —

Name of dog ______________________________________________

Description of dog __________________________________________ (gender, age, sterilisation status, breed (if known), colour)

__________________________________________

Has been registered by —

Name ____________________________________________________ (person’s full name or organisation/company name)

Street Address _____________________________________________

Suburb/Town ______________________________ Postcode _______

By (insert name of local government)

________________________________________________________

Registration number of dog _______________________________________

This registration expires on ____/____/______

Fee paid $_______________

Form 6

[r. 26]

Dog Act 1976 s. 29(8)(a) and (8A)(a)

Notice of the seizure and detention of a dog

(Place) ______________________________________

(Date) ______________________________________

To ___________________________________________________________

(insert name and address of owner or owner’s delegate)

TAKE NOTICE that a dog, of which you are the owner or owner’s delegate, has been seized and detained under the powers conferred by the Dog Act 1976 section 29(3)(d) OR under a warrant issued under the Dog Act 1976 section 29(5a) (delete whichever does not apply)

and is now at __________________________________________________

_____________________________________________________________

The registered number of the dog is _________________________________

If not claimed within 7 days from the date of the service of this notice, the dog will be destroyed or otherwise disposed of in accordance with the Dog Act 1976 and the owner is liable for the cost of the dog’s destruction and disposal.

If the dog is seized and detained under the Dog Act 1976 section 29(3)(d), the owner is liable for the costs of the dog’s detention, return and maintenance in addition to fees, charges, expenses and penalties in accordance with section 29(4).

If the dog is seized and detained under a warrant the owner is liable for the costs of the dog’s maintenance in accordance with section 29(8A)(e).

_______________________________

(to be signed by a police officer or an authorised person)

Form 7

[r. 32]

Dog Act 1976 s. 38(2)

Complaint as to a nuisance created by a dog

To ___________________________________________________________

(insert name of local government)

TAKE NOTICE that a dog, believed to be a __________________________ ⁽¹⁾

has created a nuisance by ⁽²⁾ _______________________________________

______________________________________________________________

The dog is believed to be owned by ⁽³⁾ _______________________________

and is ordinarily kept at ⁽⁴⁾ _________________________________________

and I/we ⁽⁵⁾ ________________________ of __________________________

request the local government to institute proceedings if the nuisance does not stop and undertake —

(a)

to give full information to the local government as to this matter; and

(b)

to appear in court and give evidence as a witness to the truth of this complaint.

Dated the __________________ day of _____________________ 20______

____________________________

(to be signed by the complainant/s)

(1)

Insert breed or kind of dog and, where possible, its name, gender and identifying marks.

(2)

Describe details of the alleged nuisance, including the kind of nuisance and, where possible, the dates and time on or between which the nuisance occurred, and where the dog was at the time of the nuisance.

(3)

State name and address of the person believed to be the owner.

(4)

State, if known, where the dog is ordinarily kept.

(5)

Insert name and address of each person making the complaint.

[Form 7 amended: Gazette 20 May 2014 p. 1605.]

Form 8A

[r. 33A]

Dog Act 1976 s. 38(3)

Order to prevent a dog being a nuisance

To ____________________________________________________

(insert name of person liable for the control of the dog)

I am satisfied that a dog _________________________________ ⁽¹⁾

is a nuisance by ⁽²⁾ ________________________________________

_______________________________________________________

The dog is believed to be owned by ⁽³⁾ ________________________

and is ordinarily kept at ⁽⁴⁾ __________________________________

THIS ORDER requires you to prevent the nuisance behaviour described above by ......................./.............................../ 20..................

This order will be in effect for a period of 6 months after the day on which it is issued.

Failure to comply with the order during the period in which it has effect may result in a penalty.⁽⁵⁾

Issued the ____________ day of ___________________ 20_______

____________________________

(Name and signature of authorised person)

(1)

Insert breed or kind of dog, registration number and, where possible, its name, gender and identifying marks.

(2)

Describe details of the nuisance, including the kind of nuisance and, where possible, the dates and time on or between which the nuisance occurred, and where the dog was at the time of the nuisance.

(3)

State name and address of the person believed to be the owner.

(4)

State, if known, where the dog is ordinarily kept.

(5)

Penalty for an offence relating to a dangerous dog — a fine of $10 000 with a minimum of $500 and a fine of $500 for each separate and further offence.

Penalty for an offence relating to a dog other than a dangerous dog — a fine of $5 000.

[Form 8A inserted: Gazette 20 May 2014 p. 1605‑6.]

Form 8

[r. 35(1)]

Infringement notice

Dog Act 1976 Infringement notice		Infringement notice no.
Alleged offender	Name Family name
	Given names
	or Company name _____________________________________________ ACN
	Address _____________________________________________ Postcode
Alleged offence	Description of offence _____________________________________________
	Dog Act 1976 s. or Dog Regulations 2013 r.
	Date / /20 Time a.m./p.m.
	Modified penalty $
Authorised person/designated person/officer issuing notice	Name
	Signature
	Office
Date	Date of notice / /20
Notice to alleged offender	It is alleged that you have committed the above offence. If you do not want to be prosecuted in court for the offence, pay the modified penalty within 28 days after the date of this notice. If you do not pay the modified penalty within 28 days, you may be prosecuted or enforcement action may be taken under the Fines, Penalties and Infringement Notices Enforcement Act 1994. Under that Act, some or all of the following action may be taken — your driver’s licence may be suspended, your vehicle licence may be suspended or cancelled, you may be disqualified from holding or obtaining a driver’s licence or vehicle licence, your vehicle may be immobilised or have its number plates removed, your details may be published on a website, your earnings or bank accounts may be garnished, and your property may be seized and sold. If you need more time to pay the modified penalty, you can apply for an extension of time by writing to the Authorised Person or designated person at the above postal address. If you want this matter to be dealt with by prosecution in court, sign here — ____________________________________________ and post this notice to — CEO — Dog Act 1976 [relevant local government and address] Or Designated person — Dog Act 1976 [Department and address] within 28 days after the date of this notice.

[Form 8 amended: SL 2020/99 r. 8; SL 2020/169 r. 8; SL 2024/246 r. 15.]

Form 9

[r. 35(5)]

Withdrawal of infringement notice

Dog Act 1976 Withdrawal of infringement notice		Withdrawal no.
Alleged offender	Name Family name
	Given names
	or Company name ______________________________________________ ACN
	Address ______________________________________________ Postcode
Infringement notice	Infringement notice no.
	Date of issue / /20
Alleged offence	Description of offence ______________________________________________
	Dog Act 1976 s. or Dog Regulations 2013 r.
	Date / /20 Time a.m./p.m.
CEO withdrawing notice/designated person acting on behalf of the CEO withdrawing notice	Name
	Signature
	[Relevant local government or Department]
Date	Date of withdrawal / /20
Withdrawal of infringement notice [*delete whichever is not applicable]	The above infringement notice issued against you has been withdrawn. If you have already paid the modified penalty for the alleged offence you are entitled to a refund. * Your refund is enclosed. or * If you have paid the modified penalty but a refund is not enclosed, to claim your refund sign this notice and post it to — CEO — Dog Act 1976 [relevant local government and address] or CEO/designated person acting on behalf of the CEO — Dog Act 1976 [Department and address] Signature / /20

[Form 9 amended: SL 2024/246 r. 16.]

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