Free 44455.pdf - Indiana

FALCONRY LICENSE ANNUAL REPORT
State Form 44455 (R3 / 8-08) Department of Natural Resources

DEPARTMENT OF NATURAL RESOURCES

INSTRUCTIONS: 1. Please print or type information. 2. Please send to Division of Fish and Wildlife by July 31. Name of License Holder Address (Number and Street, City, State, ZIP Code)

Division of Fish and Wildlife Permit Coordinator 402 W. Washington Street, Rm. W273 Indianapolis, IN 46204-2781 Telephone: (317) 233-6527 Fax No.: (317) 232-8150

State License No.

DESCRIPTION OF RAPTORS IN POSSESSION AS OF JUNE 30 OF THIS YEAR
1. Species Sex Male Age when acquired Date acquired Marker Number How or from whom acquired Female Age

2. Species

Sex Male Female

Age

Age when acquired

Date acquired

Marker Number

How or from whom acquired

3. Species

Sex Male Female

Age

Age when acquired

Date acquired

Marker Number

How or from whom acquired

DESCRIPTION OF RAPTORS POSSESSED OR ACQUIRED SINCE JUNE 30 OF LAST YEAR BUT NO LONGER IN POSSESSION
1. Species Age when acquired Date acquired Marker Number Sex Male Escaped Died Released Transferred Date How or from whom acquired Female Age

2. Species

Age when acquired

Date acquired

Marker Number

Sex Male Female

Age

Escaped

Died

Released

Transferred

Date

How or from whom acquired

Unused Raptor Markers Possessed: If apprentice, list name of sponsor

Marker No.

Marker No. Sponsor's License No.

REPORT DUE BY JULY 31 OF EACH YEAR, AS REQUIRED BY 312 IAC 9-10-13 AGREEMENT 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 License Holder FOR OFFICE USE ONLY Database Match Comments: File Match Date