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APPLICATION FOR A SHOOTING PRESERVE LICENSE
State form 21937 (R8 / 6-09) Approved by State Board of Accounts, 2009

DEPARTMENT OF NATURAL RESOURCES Division of Fish and Wildlife 402 W. Washington St., Rm. W273 Indianapolis, IN 46204-2781 Telephone: (317) 233-6527 Fax Number: (317) 232-8150

INSTRUCTIONS: 1. Please print or type information. 2. Attach proof of ownership or control of the property (new applicants only). 3. Include fee of $100.00 made payable to the Indiana DNR.

Please check one: Name of Applicant Date of Birth

New

Renewal

Year wanted on license: September Telephone Number Driver's License Number

to April

Name of Business (if applicable) Mailing Address (Number and Street) City State County ZIP Code

Shooting Preserve Address (Number and Street) City Location of Preserve: County Number of Contiguous Acres (must be at least 100) ZIP Code Telephone Number Township Section(s)

Please list the Species of Game Birds (pheasants, quail, chukar partridges, mallard ducks) that will be released on the Shooting Preserve: Please return the completed application with the $100.00 application fee to the above address along with a copy of the deed, lease, rental agreement, or other proof of control of the land (if applicable). Under the penalties of perjury (IC 35-44-2-1), I certify that the information supplied by me is true and correct to the best of my knowledge. Signature of Applicant: Date:

FOR OFFICE USE ONLY Date Application Received License Number Approved by Comments: Date License Issued Check/Money Order Number License Year Date