Free 48566.pdf - Indiana

SCIENTIFIC PURPOSES LICENSE ANNUAL REPORT
State Form 48566 (R2 / 7-06) DEPARTMENT OF NATURAL RESOURCES

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

Name of License Holder_____________________________________________________ Annual Report for Year Ending ___________________ Address___________________________________________ City___________________________ State__________ Zip Code____________ Business/Organization Name__________________________________ Phone_________________ E-Mail______________________________
Species Collected (include eggs, feathers, blood, etc.) Collection Dates Collection Site Description (County, legal description, maps ­ listed species only *, stream name or distance from nearest bridge crossing) Number Collected Disposition (include released, banded, marked, vouchered or killed ­ where deposited)

* If an endangered species is found or collected, please include a map. For mussels, please indicate whether a live or dead shell was found and in what condition (fresh dead, weathered). A final report can be submitted, but it must contain all the above information. Copy additional sheets as necessary.

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 (including birds, fish, mammals, reptiles, and amphibians) collected under this license. Signature of License Holder__________________________________________________________________ Date__________________________________

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Species Collected (include eggs, feathers, blood, etc.)

Collection Dates

Collection Site Description (County, legal description, maps ­ listed species only *, stream name or distance from nearest bridge crossing)

Number Collected

Disposition (include released, banded, marked, vouchered or killed ­ where deposited)

Additional information