Free 47572.pdf - Indiana

NUISANCE WILD ANIMAL CONTROL ANNUAL REPORT
State Form 47572 (R2 / 10-06)

Department of Natural Resources Attn: Permit Coordinator Division of Fish and Wildlife 402 W. Washington St. Rm. W273 Indianapolis, IN 46204-2781 Phone: (317) 233-6527 Fax: (317) 232-8150

Note: 1. Please fill out a separate summary report for each county. 2. Return this report along with your renewal application by January 15 to the address above. Year County

Name Business Name (if applicable) Address City
Animal Bat Beaver Coyote Flying Squirrel Fox Squirrel Gray Squirrel Mink Muskrat Opossum Rabbit Raccoon Gray Fox Red Fox Snake (Species:_________________) Striped Skunk Turtle (Species:_________________) Other (Please specify:____________) Other (Please specify:____________) CERTIFICATION: Under the penalties of perjury (IC 35-44-2-1), I certify that the information in this report is a complete record of all of the wild animals (mammals and reptiles) captured under this permit and is true and correct to the best of my knowledge. Signature of Permit Holder __________________________________________ Date _____________________ Total Number Captured

State
Number Released Number Killed or Euthanized

ZIP Code
Method Used (kill-trap, gunshot, euthanasia, etc.)