Free 27020.pdf - Indiana

APPLICATION FOR WILD ANIMAL REHABILITATION PERMIT
State Form 27020 (R7/ 7-08)

DEPARTMENT OF NATURAL RESOURCES

DEPARTMENT OF NATURAL RESOURCES DIVISION OF FISH AND WILDLIFE 402 W. Washington St., Rm. W273 Indianapolis, IN 46204-2781 Telephone: (317) 233-6527 Fax Number: (317) 232-8150

INSTRUCTIONS: 1. Please print or type information. 2. Be sure to read all regulations. 3. Attach additional sheets for explanation if necessary. 4. All sections must be complete before submitting to the address shown above.

Check one: Name of applicant

New Applicant
Last name

Renewal (Annual Report Required) Date
First name Middle initial

Date of birth Address (number and street or rural route) City County E-mail address

Driver's License number State Telephone number ( ZIP code )

SPECIES INTENDED TO REHABILITATE Mammals: Reptiles: Amphibians: Birds*: Yes Yes Yes Yes No No No No If yes, please list species: If yes, please list species: If yes, please list species: If yes, please provide your federal permit number: Yes No Yes No If yes, under whose name?

*If you do not have a federal permit number, do you have one pending? *Are you a sub-permittee under someone else's name?

For New Applicants: 1. 2. Have you been an assistant under a licensed rehabilitator or veterinarian? Yes No If yes, under whose name and length of time as an assistant: Please provide the experience, education, and/or training that you have had in the care and handling of wild animals. Please provide dates.

3.

List the wildlife rehabilitation reference materials (names of books, articles, etc.) that you possess. (Internet only is not

acceptable.):

Page 1 of 2

4.

Please list the facilities, equipment and supplies you have on hand that will be used. Please be sure to list all of the cages

and their sizes.

Note: Please attach additional pages if necessary to completely answer the questions. For New Applicants and Renewals Mailed After January 15: Please Have a Licensed Veterinarian (D.V.M.) Complete This Section Before Submitting: I, , have had previous experience in the care of the wild animals listed on this application form and will assist the applicant with medical treatment of wild animals when necessary. Signature of veterinarian Name of business Address of business (number and street, city, state, and ZIP code) For All Applicants: Individuals Who Will Assist Applicant 1) Name Address 2) Name Address 3) Name Address City City City Telephone number ( State Telephone number ( State Telephone number ( State ) ZIP code ) ZIP code ) ZIP code Date Telephone number ( )

A conservation officer may enter the premises of the permittee at all reasonable hours to inspect those premises and any records relative to this permit. Please return completed application to: Permit Coordinator Division of Fish and Wildlife 402 W. Washington Street, Room W273 Indianapolis, IN 46204 AGREEMENT I understand the regulations governing the rehabilitation of wild animals 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. Signature of applicant _____________________________________________ FOR OFFICE USE ONLY Date application received Approved by Comments: Page 2 of 2 Date permit issued Date approved Expiration date Date ___________________________