Free 21945.pdf - Indiana

APPLICATION FOR SCIENTIFIC PURPOSES LICENSE
State Form 21945 (R6 / 8-08) Approved by State Board of Accounts, 2008

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INSTRUCTIONS: 1. Please print or type information. 2. Be sure to read all regulations. 3. Please allow 1-2 weeks for processing.

DEPARTMENT OF NATURAL RESOURCES Division of Fish and Wildlife Attn: Operations Staff Specialist 402 W. Washington St., Rm. W273 Indianapolis, IN 46204-2781 Telephone: (317) 233-6527 Fax Number: (317) 232-8150

FEE: $10.00

New

Renewal

Date Date of Birth

Name (Last, First, Middle Initial) Applicant's Occupation and Education Level Applicant's Affiliation Business Address (Number and Street or Rural Route) City Telephone Number ( ) State E-Mail Address Mammals Birds

ZIP Code

Please check all that apply for the type of species to be collected: Amphibians 1. Live mussels Dead shells

Fish

Reptiles Nests and eggs

Crustaceans

Please provide a detailed written description of the purpose of your study for each type of species. The description must include the purpose of the work, the types or names of species to be collected (small mammals, birds, etc.) and the collection methods (electrofishing, live trapping, etc.). Please attach a proposal or additional pages if necessary to completely describe your study.

2. Please describe the location where the work will be done (county, etc.). For fish and mussel surveys, please indicate the county and the lake or stream name.

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3. Please indicate whether all specimens will be released or if any will be retained or killed. If any specimens are to be retained or killed (inc. vouchered), please indicate the maximum number of specimens/species you are requesting.

4. Where will voucher specimens (if any) be stored (include name and city and state)? ____________________________

5. Will any type of drug, vaccine, steroid, micro-organism or other chemical be administered to any specimens that are being later returned to the wild? Yes No If yes, please attach written approval from a licensed veterinarian or a university Animal Care and Use Committee for permission to use the chemical for the purpose indicated on this application form. 6. Will any specimens be marked in any way or genetically modified and then later returned to the wild? Yes No If yes, please list the types of markers that will be used: _____________________________________________________ 7. 8. Will any work be done on public property (nature preserve, etc.)? Yes No If yes, please provide the name(s): Yes No

Will any federally protected or endangered species be captured or potentially be captured? If yes, please attach a copy of your federal permit for the work outlined in this application. Please attach your proposal or additional pages if necessary. AGREEMENT

I have read and understand the regulations governing the scientific purposes license and agree to abide by them. Under penalty 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. Please send the completed application with any attachments and a check or money order made payable to the Indiana DNR in the amount of $10.00 to the address listed on page 1. Signature of Applicant NEW APPLICANTS State law in Indiana Code 14-22-22-2 requires new applicants to obtain the signatures of two scientists in a relevant field to serve as references. These references should sign below or you must attach an original, signed letter of reference from each. 1) Signature of Reference (Scientist/Biologist) Printed Name Address (number and street, city, state, ZIP code) 2) Signature of Reference (Scientist/Biologist) Printed Name Address (number and street, city, state, ZIP code) FOR OFFICE USE ONLY Date Application Received License Number Approved by Comments Date License Issued Date Check/Money Order Number License Year Occupation Occupation Date

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