Online Form - Rangers - Dog Attack Statement - Dog Owner or Person in Control

Introduction

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Location incident
Do you speak and understand English? *
Are you affected by alcohol or any drugs? *
Are you...?

Personal information

Gender *

Contact details

Current residential address

Description of your dog/s

Gender of the dog *
is/are the dog registered *
Is/are the dogs/s microchipped? *
Are you aware of an incident regarding an alleged dog attack? *
Was anyone else looking after your dog/s at the time of the incident? *
If not, where does the dog/s ordinarily live?
Were there any injuries? *

Details of the incident - Part A

Were there any witnesses to the incident? If Yes, provide names and contact details on the next page *

Witness details

Details of the incident - Part B

Where were you at the time of the incident?

Details of the incident - Part C

Has the dog/s ever shown any aggressive behaviour in the past? *
Has the dog/s ever been declared dangerous, within the Town or within another jurisdiction? *
Have you ever received infringements or been convicted for breaches of the Dog Act 1976 (WA)?
Maximum size of ALL attachments is 976.56 MB

Declaration

Have you been made any promises or inducement to provide this statement? *
Is this statement made of your own free will? *
Have you been threatened by any person to make this statement? *
Do you agree this is a true statement? *
Do you understand that by making this statement that if it is tendered in evidence I will be guilty of a crime if I have willfully included in this statement anything, which I know to be false, or that I do not believe to be true? *

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