Application to be registered as a rehomer for the Wild Horse Domestication (rehoming) Program

Section 1: Applicant details

Full name

Address

Contact phone

Are you over 18 years of age?

YesNo

Section 2: Applicant property details

Are you applying on behalf of a group, organisation or company?

YesNo

Group, organisation or company details

If yes, group, organisation or company name

Address

Phone

Section 3: Applicant horse experience

Do you have any wild horse experience or experience with unstarted (unbroken) horses?

YesNo

If yes, provide details:

Attach a written reference (no more than 3 months from the date of application) from a practicing veterinarian indicating your experience in horse care

Section 5: Intended use of animals

What is the intended use of the horses?

Provide detail. Include any intention to sell or transfer the animals?

Section 6: Previous misconduct or offences

Have you ever been subject to investigation or convicted of any animal welfare related offence (including but not limited to the following legislation: Prevention of Cruelty to Animals Act 1979, Exhibited Animals Protection Act 1986, the Animal Research Act 1985 and supporting regulations)?

YesNo

If yes, provide details

Attach evidence or documentation from any previous non-compliance or enforcement action

Are you listed on the NSW Racing Excluded List
(or comparable interstate authority)?

YesNO

Have you been convicted for an offence involving fraud or dishonesty, or been subject to an inquiry by ICAC (or an equivalent body in a jurisdiction in Australia) where a finding of corrupt conduct has been made within the previous 10 years?

YesNo

If yes, provide details:

Section 7: Sharing personal information on the department's website

I consent to my personal information, specifically my name, email and phone number being published on the department's website for the purposes of individuals, groups or organisations contacting me to obtain a rehomed horse.

YesNoSee the Privacy Statement at the end of this Form for further information.

Section 9: Declaration

By signing this form, I declare:

I will comply with my obligations at law in relation to the horses and animal welfare, including but not limited to the Prevention of Cruelty to Animals Act 1979, Exhibited Animals Protection Act 1986, the Animal Research Act 1985 and supporting regulations (as applicable to the context).
I have read, understand and agree to the above terms and conditions and the Rehoming Guidelines.
The information I have supplied is accurate, true and correct. Noting is an offence to provide false and misleading information under the Crimes Act 1900.
I will notify NSW National Parks and Wildlife Service in writing as soon as practicable if any of the information in this application changes during the Approval Period.

Privacy Statement

The Department of Climate Change, Energy, the Environment and Water (Department) collects and handles your personal information in accordance with the NSW Privacy and Personal Information Protection Act 1998. The information you provide on this form will be used by the department for the purposes of considering your application for the program, verifying your identity for the program and if your application is approved, to publish your name, phone and email on the department's website so other persons seeking to obtain a rehomed animal can contact you. Your personal information may also be disclosed to the NSW Department of Primary Industry, NSW Police and the RSPCA. The provision of this information is voluntary and is required as part of your application to be registered for the program. If you do not provide all the information, the department may not be able to consider your application. You may contact the department to access or update your information. The department is located at 12 Darcy Street, Parramatta NSW.

Signature of individual applicant

Date

Signature of company

Executed by:

ACN

In accordance with section 127(1) of the Corporations Act 2001 (Cth) acting by:

Name of Secretary/Director

Signature of Secretary/Director

Date

Name of Director

Signature of Director

Date