Free 03071.pdf - Indiana

APPLICATION FOR BAIT DEALER'S LICENSE
State Form 3071 (R7 / 4-08) Approved by State Board of Accounts, 2008

DEPARTMENT OF NATURAL RESOURCES

Instructions:

1. Please type or print information. 2. Be sure to read all regulations. 3. All sections must be complete before submitting. 4. Mail completed application to address shown at right.

Attn: Commercial License Clerk Division of Fish and Wildlife 402 W. Washington St., Rm. W273 Indianapolis, IN 46204-2781 Telephone: (317) 232-4102 Fax Number: (317) 232-8150

A Bait Dealer's License is required for the sale of minnows and crayfish. Check One: New Applicant Renewal (License expires at end of calendar year.) Non-Resident Bait Dealer (FEE: $50.00) Today's Date

Year Wanted on License Check one:

Resident Bait Dealer (FEE: $10.00)

Name of Applicant Name of Business (if applicable) Address (Number and Street or Rural Route) City County Business Information: Business Address (if different from above): City County How is bait obtained? Do you sell bait? Seine Wholesale Purchase Retail State State

ZIP Code )

Telephone Number (

ZIP Code )

Telephone Number ( Raise in Own Ponds

If bait is purchased, please provide the following information: Name Address City, State, ZIP code Please return the completed application with the license fee to the address listed above. 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. I have read and understand the laws governing the bait dealer's license and agree to abide by them. Signature of Applicant: Date:

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