Free 25298.pdf - Indiana

APPLICATION FOR CHARTER BOAT OPERATOR'S LICENSE
State Form 25298 (R4/ 8-08) Approved by State Board of Accounts, 2008

INSTRUCTIONS: 1. BE SURE TO READ REGULATIONS. 2. Please print or type information. 3. Mail completed application with license fee to address in upper right corner.

Department of Natural Resources Division of Fish and Wildlife Permit Coordinator 402 W. Washington St., W273 Indianapolis, IN 46204-2781 Phone: (317) 232-4102 Fax: (317) 232-8150

License Fee: $100.00

Check one:

New

Renewal

Date of Application Old License Number Driver's License Number Date of Birth County

Year wanted on License (license expires at end of calendar year) Name of Applicant Address (rural route or number and street) City, State and Zip Code Telephone Number ( Name of Business Business Address (if different than above) Lake(s) or river(s) where charter boat operation will occur under this license: ) E-mail Address

Business Telephone Number (

)

Name of Boat

Boat Registration Number Yes No

Do you wish to be listed on the Division of Fish and Wildlife website as a licensed Charter Boat Operator?

Note: Only the information provided on this application will be used. Application must be received and processed by March 1 for inclusion.

Please make check or money order payable to the Indiana DNR, Division of Fish and Wildlife, in the amount of $100.00 and mail it with your completed application form. Under the penalties of perjury (IC 35-44-2-1), I certify that the information supplied by me is correct to the best of my knowledge. Signature of Applicant: Date Signed:

FOR OFFICE USE ONLY Month Fished (Yes/No) Date Received Date Application Received Approved by License Year License Number Check/Money Order Number Date Approved Date License Issued Jan. Feb. Mar. Apr. May June July Aug. Sep. Oct. Nov. Dec.