Free 03230.pdf - Indiana

APPLICATION FOR TAXIDERMIST LICENSE
State Form 3230 (R7/9-06) Approved by State Board of Accounts 2006

DEPARTMENT OF NATURAL RESOURCES

Instructions:

1. Please type or print information. 2. Be sure to read all laws. 3. All sections must be complete before submitting. 4. Mail completed application with license fee 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) 233-6527 Fax Number: (317) 232-8150

LICENSE FEE: $15.00 (Check or Money Order should be made payable to the Division of Fish and Wildlife) Check One: New Applicant Renewal Today's Date______________________

Year Wanted on License __________ (License expires at end of calendar year) Phone Number (_____)______________ Name of Applicant_______________________________________________ Address (Number and Street or Rural Route)______________________________________________________________ City______________________________ County____________________________ State__________ ZIP Code____________

E-Mail Address ________________________________________________ Mammals Birds Fish Reptiles

For which of the following do you provide taxidermy services?

Do you have a federal permit to provide taxidermy services for Migratory Birds (includes raptors, songbirds and waterfowl)? Yes No If yes, please provide the federal permit number or date applied for: __________________

Name of Business or Employment of taxidermy work ______________________________________________________ Address (if same as above leave blank) __________________________________________________________________ City_______________________________ County_____________________________ State__________ ZIP Code____________

Business Phone Number (________)_________________

Please return the completed application with the $15.00 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 taxidermy license and agree to abide by them. Signature of Applicant: ____________________________________________ Date:___________________

FOR OFFICE USE ONLY Date Application Received ______________ Check/Money Order Number ___________________ License Number ____________ Date License Issued _______________ License Year ________

Approved by _________________________________________ Date ______________________