Free 42480.FH11 - Indiana

APPLICATION FOR A DUPLICATE LICENSE

State Form 42480 (R3/11-01) Approved by the State Board of Accounts 2001 Check the type duplicate license for which you are applying.

RETURN ALL THREE COPIES TO: INDIANA DEPARTMENT OF NATURAL RESOURCES Division of Fish and Wildlife 402 W. Washington St. Rm W273 Indianapolis, IN 46204

Resident Deer Muzzleloader $12.00 Resident Deer Archery Resident Deer Firearm Resident Extra Deer Archery Bonus Antlerless Deer Resident Annual Youth Hunting & Fishing Resident Turkey Resident 1-day Fishing $12.00 $12.00 $12.00 $12.00 $4.00 $12.00 $4.00

Resident Hunting Resident Fishing Resident Hunting and Fishing Resident Trapping Game Bird Habitat Stamp Waterfowl Stamp Trout / Salmon Stamp Total Amount Included

$7.00 $7.00 $10.00 $7.00 $4.00 $4.00 $5.00 $

AFFIDAVIT STATE OF INDIANA County of _________________________________________________________________ I, _____________________________________________________________________after being duly sworn, depose and say, that I am a resident of the State of Indiana and have resided in Indiana for the past __________ years, __________ months and now reside at: _________________________________________________________________________
Street and number

_________________________________________ and ___________________________;
City, State and ZIP code Area code and telephone number

that my occupation is _________________________________________; that my personal description is: Age _______, Date of Birth ________________________, Ht.________, Wt. _______, Sex _______, Hair Color ________________, Eye Color ___________; and I did purchase a ___________________________ from ____________________________
Year and name of license checked above Name of retail outlet

on or about the date of ____________________________ and that said license has been: Lost Destroyed Stolen SIGNATURE AND VERIFICATION I, ___________________________________, certify that my license has not been revoked by any court action or by the Department of Natural Resources, nor, is there any court action pending against me for hunting, trapping or fishing in this state in violation of the Indiana Fish and Wildlife Act.
Signature of affiant Date signed

Sworn to and subscribed before me, a Notary, in and for the County of ________________________________, State of Indiana, this ___________ day of _________________________________, 20_______________.
Signature of Notary Printed or typed name of Notary Date Commission expires

FOR OFFICE USE ONLY (DNR validation seal must be affixed)
Total amount received Date validated

$
Sold by: Date of expiration

DISTRIBUTION: White - Customer (after processing); Canary - License Section; Pink - Conservation Officer