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11IIII„!' IK11ITC III°°1 E IIS II <br /> < > Dog Deslignabon Appeal IHearing Request(Form <br /> .l Y li 18 m-,R. <br /> To file an appeal to your dog designation, complete the following, which must be received by the City <br /> Clerk within five working days of you receiving the Notice of Dog Designation from the Animal Welfare <br /> Agency South Central Ontario, formally referred to as Kitchener-Waterloo & North Waterloo Humane <br /> Society. <br /> Note: If you request an appeal hearing: <br /> • you will receive a Notice of Hearing to attend the Dog Designation Appeal Committee meeting-, <br /> • the Notice of Hearing will be sent by Registered Mail to the address you provide-, <br /> • the recommendation of the Committee is not final until ratified by City Council-, and, <br /> • City Council may confirm, rescind, modify, or substitute any recommendation from the <br /> Committee. <br /> Full Name: <br /> Last First M.I. <br /> Address: <br /> Street Address Apartment/Unit# <br /> City Province Postal Code <br /> Phone: Email <br /> Name: Licence# <br /> Breed: Age Of Dog: <br /> Date Designated: <br /> Type of Designation:❑POTENTIALLY DANGEROUS ❑ DANGEROUS ❑ PROHIBITED ❑RESTRICTED <br /> Appealing: ❑ the entire designation ❑ only specific conditions of the designation <br /> Please describe the reason for your appeal including any concerns with specific conditions of the designation: <br /> � II tm <br /> The Animal Welfare Agency South Central Ontario has been contracted to enforce the City's animal <br /> control by-laws-,accordingly,the City's Legal Services staff will represent the City at the appeal hearing. <br /> The Animal Welfare Agency South Central Ontario's officer will often be called as a witness by the <br /> City's Lawyer at the appeal hearing.Please indicate below if you would like to meet with Legal Services <br /> Staff in advance of the appeal hearing to discuss the designation. Please note, City Staff are not <br /> permitted to provide you with any legal advice. <br /> ❑ Yes ❑ No <br /> Signed this day of 20_ <br /> Applicant's Signature(s) <br />