Free 27021.pdf - Indiana

APPLICATION FOR FALCONRY LICENSE
State Form 27021 (R3 / 1-08) Approved by State Board of Accounts 2008 Department of Natural Resources

FEE: $60.00
Instructions: 1. Please type or print information. 2. Be sure to read all regulations. 3. Mail completed application and license fee to address show at right.

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

Name of Applicant (First, Middle Initial, Last) Address (Number and Street or Rural Route) City County Date of Birth State Telephone Number ( E-Mail Address ZIP Code )

Address where facilities will be located (if different than above) Class of license requested: Apprentice General Master

Number of years possessing falconry license

Previous falconry license number (if applicable)

If apprentice, list name and license number of sponsoring adult: Name of Sponsor License Number DESCRIPTION OF RAPTORS POSSESSED #1 Species How acquired #2 Species How acquired #3 Species How acquired Sex Age Age when acquired Marker Number Age when acquired Marker Number Age when acquired Marker Number

Date acquired (month, day, year) Sex Age

Date acquired (month, day, year) Sex Age

Date acquired (month, day, year)

Please mail check or money order in the amount of $60.00, payable to the Indiana Division of Fish and Wildlife, to the address listed at the top of the page. I have read and understand the regulations and agree to abide by them. I certify under penalties of perjury (IC 35-44-2-1), that the information supplied by me is true and correct. Signature of Applicant Date

FOR OFFICE USE ONLY Issue Date: License Number: Comments: Exp. Date: Approved by: Check Number: