Free 51815.pdf - Indiana

APPLICATION FOR SPECIAL PURPOSE EDUCATIONAL PERMIT
State Form 51815 (R / 7-08)

INSTRUCTIONS: 1. Please print or type information. 2. Attach additional sheets for explanation if necessary. 3. All sections must be complete before submitting. Please check one: New Applicant Renewal (Annual Report Required)

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

Name of Applicant
Last Name First Name Middle Initial

Date Applicant's Driver's License Number Telephone Number ( State ZIP Code ) County

Date of Birth Street Address City E-Mail Address

Educational Institution/Organization Information Name of Educational Institution or Organization Applicant's Position with Institution/Organization Describe the type of Institution/Organization Business Address (if different from above) Business Telephone Number ( 1. )

Please list the species of wild animal(s) that will be used for educational purposes: Yes Yes Yes No No No If yes, please list: If yes, please list: If yes, please list:

MAMMALS: REPTILES: BIRDS*: subpermittee:

*For birds, please provide your federal permit number or name of person on whose permit you are listed as a 2. Please describe how the animal was obtained (rehabilitation, purchase, etc.) and attach documentation (new applications or animals only).

3. If the animals were obtained under a rehabilitation permit, are they permanently injured and non-releasable? Yes No If no, please explain: Page 1 of 2

4. What is the purpose of your educational program? 5. Please list the names and addresses of individuals (if any) who will be assisting you: 1) Name Address (City, State, ZIP Code) 2) Name Address (City, State, ZIP Code) 3) Name Address (City, State, ZIP Code) 6. Please list the names of schools or other organizations to whom educational programs will be given: Telephone Number Telephone Number Telephone Number

7.

Please attach an outline of the educational program, including as much detail as possible. NOTE: If additional space is needed, list information on another sheet. AGREEMENT

I have read and understand the regulations and agree to use the animals listed hereon for educational purposes in accordance with the regulations. 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 Approved by Comments Date Approved

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