Dog Desexing Incentive Draw

1.

Are you a resident of the Isaac Region? *

* required

Yes

No

2.

Is your animal a dog? *

* required

Yes

No

3.

Was your dog desexed within the last three months? *

* required

Yes

No

4.

Is the dog registered with Isaac Regional Council? *

* required

Yes

No

5.

Is your dog microchipped? *

* required

Yes

No

6.

Title *

* required

Mr

Mrs

Miss

Ms

Dr

Other (please specify)

7.

First/Given Name *

* required

Maximum 255 characters

0/255

8.

Last/Family Name *

* required

Maximum 255 characters

0/255

9.

Residential Address *

* required

Maximum 255 characters

0/255

10.

Town *

* required

Carmila

Clairview

Clarke Creek

Clermont

Coppabella

Dysart

Flaggy Rock

Glenden

Greenhill

Ilbilbie

Kilcummin

Middlemount

Mistake Creek

Moranbah

Nebo

St. Lawrence

Valkyrie

11.

Contact Phone Number *

* required

Maximum 255 characters

0/255

12.

Email

13.

Dog's Name *

* required

Maximum 255 characters

0/255

14.

Green Registration Tag Number

Maximum 255 characters

0/255

15.

Microchip Number *

* required

Maximum 255 characters

0/255

Your dog must be microchipped to be eligible for this draw.

16.

Desexing Proof *

* required

Your dog must be desexed within the last three months to be eligible for this draw. Please attach the proof of desexing.

17.

I declare that I am the legal owner of the animal described in this form and all the details provided are true and correct. *

* required

Yes

18.

I understand that my information will not be shared or distributed in any way. *

* required

Yes