Free 50650.pdf - Indiana

INDIANA GAME BREEDER'S LICENSE INVENTORY AND TRANSACTION RECORD
State Form 50650 (R3 / 7-09) Department of Natural Resources

DEPARTMENT OF NATURAL RESOURCES

INSTRUCTIONS: 1. This record is to be completed for each addition or deletion to your inventory for the license year listed. 2. Please attach additional pages if more space is needed. 3. Please fill out a separate sheet for each site where animals are housed. 4. You must retain this record for at least two (2) years after each deletion or addition, and it must be provided to a conservation officer upon request. Year License Number County ______

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

Name of License Holder (first, middle initial, last) Physical Address (number and street or rural route, city, and ZIP code ­ no post office boxes)

Please fill in all information requested below for each animal that was sold, bought, traded, loaned, bartered, gifted, born, died, or escaped:
DATE (month, day, year) TYPE (Bought, Sold, Born, Died, Gifted, Etc.) SPECIES OF ANIMAL NUMBER OF ANIMALS (Bought, Sold, Etc.) NAME AND ADDRESS OF PERSON TO WHOM SOLD, PURCHASED, OR TRANSFERRED [IF ESCAPED, NAME OF CONSERVATION OFFICER NOTIFIED-INCLUDE DATE,TIME AND MEANS NOTIFIED] (include complete address) NUMBER ON HAND