Free 47058.pdf - Indiana

APPLICATION FOR INDIANA AQUACULTURE PERMIT
State Form 47058 (R5 / 6-08) DDEPARTMENT OF NATURAL RESOURCES

DEPARTMENT OF NATURAL RESOURCES Attn: Commercial License Clerk Division of Fish and Wildlife 402 W. Washington St., Rm W273 Indianapolis, IN 46204-2781 Phone: (317) 232-4094 Fax: (317) 232-8150

Instructions:

1. Please type or print information. 2. Be sure to read all regulations.

This free permit is required to import, raise, sell or transport grass carp into or within Indiana, as required by 312 IAC 9-10-17.

Please check one:

New

Renewal

Date

Name of Company or Organization Name of Applicant/Principal Officer (first, last) Address (number and street) City, State, Zip Code County Website Telephone Number ( E-Mail Address Species of fish requested to be imported, purchased, sold or transported: Grass Carp Diploid Triploid Other (please specify) Fish will be raised and sold for: Human or animal consumption Stocking into private waters Other (please specify) )

Do you wish to be listed on the Division of Fish and Wildlife website? Yes No Note: Only the information provided on this application will be used on the website. Application must be received and processed by February 1 for inclusion on website. Please return completed application to: Permit Coordinator Division of Fish and Wildlife 402 W. Washington Street, Room W273 Indianapolis, IN 46204 AGREEMENT I have read and understand the regulations for the aquaculture permit and agree to abide by them. Under the penalties of perjury (IC 35-44-2-1), I affirm that the information supplied by me is true and correct to the best of my knowledge. Signature of Applicant Date

FOR OFFICE USE ONLY Approved Comments/Notes Disapproved Permit number issued Expiration Date

Signature of Fisheries Staff Specialist