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Online Form - Dog Attack Report
Dog Act 1976
Complainant
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AUSTRALIA
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ST VINCENT & GRENADINES
SAIPAN
SAMOA
SAMOA AMERICAN
SAN MARINO
SAO TOME & PRINCIPE
SAUDI ARABIA
SENEGAL
SERBIA
SEYCHELLES
SIERRA LEONE
SINGAPORE
SLOVAKIA
SLOVENIA
SOLOMON ISLANDS
SOMALIA
SOUTH AFRICA
SPAIN
SRI LANKA
SUDAN
SURINAME
SWAZILAND
SWEDEN
SWITZERLAND
SYRIA
TAHITI
TAIWAN
TAJIKISTAN
TANZANIA
THAILAND
TOGO
TOKELAU
TONGA
TRINIDAD & TOBAGO
TUNISIA
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UGANDA
UKRAINE
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VIRGIN ISLANDS (BRIT)
VIRGIN ISLANDS (USA)
WAKE ISLAND
WALLIS & FUTANA IS
YEMEN
ZAIRE
ZAMBIA
ZIMBABWE
Contact Number - HOME
Contact Number - MOBILE
*
Contact Number - WORK
Email
*
Victim Details (person or dog)
Full Name
*
Residential Address
Residential Address:
*
City:
*
State:
*
Post Code:
*
Country:
*
Select Country >>
AUSTRALIA
--------
AFGANISTAN
ALBANIA
ALGERIA
AMERICAN SAMOA
ANDORRA
ANGOLA
ANGUILLA
ANTIGUA & BARBUDA
ARGENTINA
ARMENIA
ARUBA
AUSTRALIA
AUSTRIA
AZERBAIJAN
BAHAMAS
BAHRAIN
BANGLADESH
BARBADOS
BELARUS
BELGIUM
BELIZE
BENIN
BERMUDA
BHUTAN
BOLIVIA
BONAIRE
BOSNIA & HERZEGOVINA
BOTSWANA
BRAZIL
BRITISH INDIAN OCEAN TER
BRUNEI
BULGARIA
BURKINA FASO
BURUNDI
CAMBODIA
CAMEROON
CANADA
CANARY ISLANDS
CAPE VERDE
CAYMAN ISLANDS
CENTRAL AFRICAN REPUBLIC
CHAD
CHANNEL ISLANDS
CHILE
CHINA
CHRISTMAS ISLAND
COCOS ISLAND
COLOMBIA
COMOROS
CONGO
COOK ISLANDS
COSTA RICA
COTE DIVOIRE
CROATIA
CUBA
CURACO
CYPRUS
CZECH REPUBLIC
DENMARK
DJIBOUTI
DOMINICA
DOMINICAN REPUBLIC
EAST TIMOR
ECUADOR
EGYPT
EL SALVADOR
EQUATORIAL GUINEA
ERITREA
ESTONIA
ETHIOPIA
FALKLAND ISLANDS
FAROE ISLANDS
FIJI
FINLAND
FRANCE
FRENCH GUIANA
FRENCH POLYNESIA
FRENCH SOUTHERN TER
GABON
GAMBIA
GEORGIA
GERMANY
GHANA
GIBRALTAR
GREAT BRITAIN
GREECE
GREENLAND
GRENADA
GUADELOUPE
GUAM
GUATEMALA
GUINEA
GUYANA
HAITI
HAWAII
HONDURAS
HONG KONG
HUNGARY
ICELAND
INDIA
INDONESIA
IRAN
IRAQ
IRELAND
ISLE OF MAN
ISRAEL
ITALY
JAMAICA
JAPAN
JORDAN
KAZAKHSTAN
KENYA
KIRIBATI
KOREA NORTH
KOREA SOUT
KUWAIT
KYRGYZSTAN
LAOS
LATVIA
LEBANON
LESOTHO
LIBERIA
LIBYA
LIECHTENSTEIN
LITHUANIA
LUXEMBOURG
MACAU
MACEDONIA
MADAGASCAR
MALAYSIA
MALAWI
MALDIVES
MALI
MALTA
MARSHALL ISLANDS
MARTINIQUE
MAURITANIA
MAURITIUS
MAYOTTE
MEXICO
MIDWAY ISLANDS
MOLDOVA
MONACO
MONGOLIA
MONTSERRAT
MOROCCO
MOZAMBIQUE
MYANMAR
NAMBIA
NAURU
NEPAL
NETHERLAND ANTILLES
NETHERLANDS
NEVIS
NEW CALEDONIA
NEW ZEALAND
NICARAGUA
NIGER
NIGERIA
NIUE
NORFOLK ISLAND
NORWAY
OMAN
PAKISTAN
PALAU ISLAND
PALESTINE
PANAMA
PAPUA NEW GUINEA
PARAGUAY
PERU
PHILLIPINES
PITCAIRN ISLAND
POLAND
PORTUGAL
PUERTO RICO
QATAR
REPUBLIC OF MONTENEGRO
REPUBLIC OF SERBIA
REUNION
ROMANIA
RUSSIA
RWANDA
ST BARTHELEMY
ST EUSTATIUS
ST HELENA
ST KITTS-NEVIS
ST LUCIA
ST MAARTEN
ST PIERRE & MIQUELON
ST VINCENT & GRENADINES
SAIPAN
SAMOA
SAMOA AMERICAN
SAN MARINO
SAO TOME & PRINCIPE
SAUDI ARABIA
SENEGAL
SERBIA
SEYCHELLES
SIERRA LEONE
SINGAPORE
SLOVAKIA
SLOVENIA
SOLOMON ISLANDS
SOMALIA
SOUTH AFRICA
SPAIN
SRI LANKA
SUDAN
SURINAME
SWAZILAND
SWEDEN
SWITZERLAND
SYRIA
TAHITI
TAIWAN
TAJIKISTAN
TANZANIA
THAILAND
TOGO
TOKELAU
TONGA
TRINIDAD & TOBAGO
TUNISIA
TURKEY
TURKMENISTAN
TURKS & CAICOS IS
TUVALU
UGANDA
UKRAINE
UNITED ARAB ERIMATES
UNITED KINGDOM
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UZBEKISTAN
VANUATU
VATICAN CITY STATE
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VIRGIN ISLANDS (USA)
WAKE ISLAND
WALLIS & FUTANA IS
YEMEN
ZAIRE
ZAMBIA
ZIMBABWE
Contact Number - HOME
Contact Number - MOBILE
*
Contact Number - WORK
Breed of Dog (if victim)
*
Attacking Dog and Owner Details (if known)
Full Name
Postal Address
Postal Address:
City:
State:
Post Code:
Country:
Select Country >>
AUSTRALIA
--------
AFGANISTAN
ALBANIA
ALGERIA
AMERICAN SAMOA
ANDORRA
ANGOLA
ANGUILLA
ANTIGUA & BARBUDA
ARGENTINA
ARMENIA
ARUBA
AUSTRALIA
AUSTRIA
AZERBAIJAN
BAHAMAS
BAHRAIN
BANGLADESH
BARBADOS
BELARUS
BELGIUM
BELIZE
BENIN
BERMUDA
BHUTAN
BOLIVIA
BONAIRE
BOSNIA & HERZEGOVINA
BOTSWANA
BRAZIL
BRITISH INDIAN OCEAN TER
BRUNEI
BULGARIA
BURKINA FASO
BURUNDI
CAMBODIA
CAMEROON
CANADA
CANARY ISLANDS
CAPE VERDE
CAYMAN ISLANDS
CENTRAL AFRICAN REPUBLIC
CHAD
CHANNEL ISLANDS
CHILE
CHINA
CHRISTMAS ISLAND
COCOS ISLAND
COLOMBIA
COMOROS
CONGO
COOK ISLANDS
COSTA RICA
COTE DIVOIRE
CROATIA
CUBA
CURACO
CYPRUS
CZECH REPUBLIC
DENMARK
DJIBOUTI
DOMINICA
DOMINICAN REPUBLIC
EAST TIMOR
ECUADOR
EGYPT
EL SALVADOR
EQUATORIAL GUINEA
ERITREA
ESTONIA
ETHIOPIA
FALKLAND ISLANDS
FAROE ISLANDS
FIJI
FINLAND
FRANCE
FRENCH GUIANA
FRENCH POLYNESIA
FRENCH SOUTHERN TER
GABON
GAMBIA
GEORGIA
GERMANY
GHANA
GIBRALTAR
GREAT BRITAIN
GREECE
GREENLAND
GRENADA
GUADELOUPE
GUAM
GUATEMALA
GUINEA
GUYANA
HAITI
HAWAII
HONDURAS
HONG KONG
HUNGARY
ICELAND
INDIA
INDONESIA
IRAN
IRAQ
IRELAND
ISLE OF MAN
ISRAEL
ITALY
JAMAICA
JAPAN
JORDAN
KAZAKHSTAN
KENYA
KIRIBATI
KOREA NORTH
KOREA SOUT
KUWAIT
KYRGYZSTAN
LAOS
LATVIA
LEBANON
LESOTHO
LIBERIA
LIBYA
LIECHTENSTEIN
LITHUANIA
LUXEMBOURG
MACAU
MACEDONIA
MADAGASCAR
MALAYSIA
MALAWI
MALDIVES
MALI
MALTA
MARSHALL ISLANDS
MARTINIQUE
MAURITANIA
MAURITIUS
MAYOTTE
MEXICO
MIDWAY ISLANDS
MOLDOVA
MONACO
MONGOLIA
MONTSERRAT
MOROCCO
MOZAMBIQUE
MYANMAR
NAMBIA
NAURU
NEPAL
NETHERLAND ANTILLES
NETHERLANDS
NEVIS
NEW CALEDONIA
NEW ZEALAND
NICARAGUA
NIGER
NIGERIA
NIUE
NORFOLK ISLAND
NORWAY
OMAN
PAKISTAN
PALAU ISLAND
PALESTINE
PANAMA
PAPUA NEW GUINEA
PARAGUAY
PERU
PHILLIPINES
PITCAIRN ISLAND
POLAND
PORTUGAL
PUERTO RICO
QATAR
REPUBLIC OF MONTENEGRO
REPUBLIC OF SERBIA
REUNION
ROMANIA
RUSSIA
RWANDA
ST BARTHELEMY
ST EUSTATIUS
ST HELENA
ST KITTS-NEVIS
ST LUCIA
ST MAARTEN
ST PIERRE & MIQUELON
ST VINCENT & GRENADINES
SAIPAN
SAMOA
SAMOA AMERICAN
SAN MARINO
SAO TOME & PRINCIPE
SAUDI ARABIA
SENEGAL
SERBIA
SEYCHELLES
SIERRA LEONE
SINGAPORE
SLOVAKIA
SLOVENIA
SOLOMON ISLANDS
SOMALIA
SOUTH AFRICA
SPAIN
SRI LANKA
SUDAN
SURINAME
SWAZILAND
SWEDEN
SWITZERLAND
SYRIA
TAHITI
TAIWAN
TAJIKISTAN
TANZANIA
THAILAND
TOGO
TOKELAU
TONGA
TRINIDAD & TOBAGO
TUNISIA
TURKEY
TURKMENISTAN
TURKS & CAICOS IS
TUVALU
UGANDA
UKRAINE
UNITED ARAB ERIMATES
UNITED KINGDOM
UNITED STATES OF AMERICA
URAGUAY
UZBEKISTAN
VANUATU
VATICAN CITY STATE
VENEZUELA
VIETNAM
VIRGIN ISLANDS (BRIT)
VIRGIN ISLANDS (USA)
WAKE ISLAND
WALLIS & FUTANA IS
YEMEN
ZAIRE
ZAMBIA
ZIMBABWE
Residential Address
Residential Address:
City:
State:
Post Code:
Country:
Select Country >>
AUSTRALIA
--------
AFGANISTAN
ALBANIA
ALGERIA
AMERICAN SAMOA
ANDORRA
ANGOLA
ANGUILLA
ANTIGUA & BARBUDA
ARGENTINA
ARMENIA
ARUBA
AUSTRALIA
AUSTRIA
AZERBAIJAN
BAHAMAS
BAHRAIN
BANGLADESH
BARBADOS
BELARUS
BELGIUM
BELIZE
BENIN
BERMUDA
BHUTAN
BOLIVIA
BONAIRE
BOSNIA & HERZEGOVINA
BOTSWANA
BRAZIL
BRITISH INDIAN OCEAN TER
BRUNEI
BULGARIA
BURKINA FASO
BURUNDI
CAMBODIA
CAMEROON
CANADA
CANARY ISLANDS
CAPE VERDE
CAYMAN ISLANDS
CENTRAL AFRICAN REPUBLIC
CHAD
CHANNEL ISLANDS
CHILE
CHINA
CHRISTMAS ISLAND
COCOS ISLAND
COLOMBIA
COMOROS
CONGO
COOK ISLANDS
COSTA RICA
COTE DIVOIRE
CROATIA
CUBA
CURACO
CYPRUS
CZECH REPUBLIC
DENMARK
DJIBOUTI
DOMINICA
DOMINICAN REPUBLIC
EAST TIMOR
ECUADOR
EGYPT
EL SALVADOR
EQUATORIAL GUINEA
ERITREA
ESTONIA
ETHIOPIA
FALKLAND ISLANDS
FAROE ISLANDS
FIJI
FINLAND
FRANCE
FRENCH GUIANA
FRENCH POLYNESIA
FRENCH SOUTHERN TER
GABON
GAMBIA
GEORGIA
GERMANY
GHANA
GIBRALTAR
GREAT BRITAIN
GREECE
GREENLAND
GRENADA
GUADELOUPE
GUAM
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Contact Number - HOME
Contact Number - MOBILE
*
Contact Number - WORK
Breed or Description of Attacking Dog
*
Was The Owner In Attendance When The Attack Occurred
*
Yes
No
Was the owner notified of the attack?:
*
Please Provide Details of any Conversation had with the Dog Owner
Details of the Attack
Date of the Attack
*
Time of the Attack
*
Location
*
Please Provide a Full Description of What Occurred
*
Was Physical Injury Caused?
Yes
No
Please Detail the Injury Caused:
*
Did the Victim Require Medical Treatment?
*
Yes
No
Please Provide Details of the Treatment Provided:
*
Was Anything Else Damaged (bike, clothing etc)
*
Yes
No
Please enter the details of what was damaged and in what way:
*
Would you be Prepared to Give Evidence in Court Regarding this Attack?
*
Yes
No
Were there any witnesses?
*
Yes
No
To the best of your ability, please provide their Name, Address and Contact Number below::
Please type your name below to signify that you agree that all information given above is true and correct at the time of submission
*
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