Working Dog Self Assessment
Checklist
Animal Management (Cats and Dogs) Act 2008
A: PO Box 887, INNISFAIL
P: 1300 763 903
E: [email protected]
Cassowary Coast Regional Council is collecting the personal information you supply on this form for the purpose of processing your
application. Council is authorised to do this under the Animal Management (Cats and Dogs) Act 2008. Your personal details will not be
disclosed to any other person or agency external to Council without your consent.
This assessment sheet is to establish whether your dog/s meets the 'Working Dog' definition
contained in the Animal Management Act 2008. A completed Application for Dog Registration must
be provided with this assessment form.
DOG OWNER DETAILS
First Names
Surname
Residential Address
Postal Address
Contact Numbers
Email
Do you live on rural land, as defined under the Animal Management Act?
Yes 
Rural land - means land used for grazing stock or cultivating crops on a commercial basis.
No 
Are you a primary producer, as defined under the Animal Management Act?
Yes 
No 
Primary producer means a person primarily engaged in one of the following occupations (please tick
relevant type)
 Dairy Farmer Grazier
General or mixed farming
livestock breeding
Are you a person engaged in primary production?
Yes 
No 
 The holder of the ABN number: ______________________________
 Employed by a primary producer:_____________________________
Employers Name:____________________________________________
Employers ABN:_____________________________________________
DOG DETAILS
Is your dog/s primarily kept for droving, protecting, tending or working the following stock?  Y N
 Cattle
Sheep
 Horses
 Goats
 Alpacas
 Llamas
 Vicunas
 Asses/Mules/Donkeys
The dogs for which I am applying (attach list if necessary)
Name
Breed
Colour
Features/
markings
PID
Y/N
Sex
M/F
Desexed
Y/N
DOB/
Age
Please provide copies of any microchipping certificates and proof of desexing in the form of a
veterinarians certificate or letter as may be applicable.
Address where dog/s reside? (if different addresses please identify which dog is at each address)
Have any of the dogs ever been declared a Regulated Dog?
If yes please provide further details:
Y
N
CHECKLIST
Please check that you have attached copies of the relevant information to this form.
 Microchip certificate (if applicable)
 Desexing certificate (if applicable)
Primary producer evidence
Completed application for dog registration
DECLARATION
I submit the working dog self-assessment checklist form with the relevant supporting documentation
as required.
I declare that the details are correct to the best of my ability.
I understand that it is an offence under s204 of Animal Management (Cats and Dogs) Act 2008 to
provide false or misleading information or documents.
Signature of Owner
Date