Free 51801.pdf - Indiana

APPLICATION FOR SPECIAL PURPOSE SALVAGE PERMIT
State Form 51801 (R / 5-08)

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 Date of Birth Street Address City E-Mail Address State First Name Middle Initial

Date

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

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

1.

Please list the species that will be salvaged: Yes Yes Yes Yes No No No No If yes, please list species: If yes, please list species: If yes, please list species: If yes, please list species:

MAMMALS: REPTILES: AMPHIBIANS: BIRDS*:

*For birds, please provide your federal permit number or name of person on whose permit you are listed as a subpermittee: 2. Please describe in detail the activity or purpose for salvaging specimens:

3. Please indicate the counties in Indiana where you will be salvaging specimens:

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4. 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) 5. Please identify the location (name of organization/business and address) where the specimens salvaged under this permit will be deposited: Name: Address: NOTE: If additional space is needed, list information on another sheet. AGREEMENT 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. Telephone Number Telephone Number Telephone Number

Signature of Applicant

Date

FOR OFFICE USE ONLY Approved by Comments Date

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