Free 03069.pdf - Indiana

APPLICATION FOR GAME BREEDER'S LICENSE
State Form 3069 (R10 / 8-07) Approved by State Board of Accounts 2007

DEPARTMENT OF NATURAL RESOURCES

FEE $15.00 Instructions: 1. Please type or print information. 2. Be sure to read all regulations. 3. Attach additional sheets for explanation if necessary. 4. All sections must be complete before submitting. New Applicant Renewal (Please be sure to submit Annual Report)

Attn: Permit Coordinator Division of Fish and Wildlife 402 W. Washington St., Rm. W273 Indianapolis, IN 46204-2781 Telephone: (317) 232-4102 Fax Number: (317) 232-8150

Check One:

Today's Date Date of Birth

Name of Applicant (First, Mid. Intl., Last) Indiana Driver's License Number Address (Number and Street or Rural Route ­ No P.O. Boxes) City State ZIP Code Bobwhite Quail Southern Flying Squirrel Red Fox Raccoon Telephone Number

County Eastern Cottontail Rabbit Beaver Mink Striped Skunk

Species of animals and/or birds (check all that apply): White-tailed Deer Ring-necked Pheasants Gray Squirrel Fox Squirrel Coyote Gray Fox Muskrat Virginia Opossum Weasel (Long-tailed or Least) Name of Business (if applicable) Business Address City Species being kept here ADDITIONAL INFORMATION: List additional location(s) where animals and/or birds are kept (if not same as above): SECOND Street Address City Species being kept here NOTE: If additional space is needed, list other animals and/or birds and required information on an additional sheet. AGREEMENT A conservation officer may enter the premises of the license holder at all reasonable hours to inspect those premises and any records relative to the license. I have read and understand the regulations for game breeder licenses and agree to abide by them. Under the penalties of perjury (IC 35-44-2-1), I affirm the information supplied by me is true and correct to the best of my knowledge. Signature of Applicant Date State ZIP Code County State ZIP Code Telephone Number County

Please make check or money order payable to DNR ­ Division of Fish and Wildlife in the amount of $15.00. Please return completed application with the $15.00 license fee to the address shown above. FOR OFFICE USE ONLY Issue Date: License Number: Comments: Exp. Date: Approved/Denied by: Check Number: Date: