Fish and Wildlife Education/Exhibition ReportForm

New York State Department of Environmental Conservation Division of Fish, Wildlife & Marine Resources ? Special Licenses Unit

625 Broadway y Albany y NY 12233-4752 y Tel (518) 402-8985

Email: fwslu@gw.dec.state.ny.us y Website: :

Fish and Wildlife Education/Exhibition Report Form

Please Refer to the Instructions before completing this report form

1. Licensee's Last Name

First Name

MI

License Type and Number

Street 1

Street 2

City/Town

State

Zip Code

County

2. Date of Birth

3. Email Address

4. Home Telephone

Work Telephone

Cell Telephone

5. Business Name (if applicable)

Street (if applicable and different from above)

City

State

Zip Code

6. Facility Address (If applicable and different from above, physical address where licensed animals are housed)

City/Town

County

Township

State

Zip code

Education/Exhibition Report Form 2/05/2013 | Page 1 of 6

Captive Animal Inventory 7.

Common Name

Sex of Listed Animal

MF U

Age 8. Disposition Code

Disposition Date

Name and License Number of Licensee or Facility (For Acquisitions or Transfers Only)

9.

Was the Animal

Used for Exhibition

Activities

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Education/Exhibition Report Form 2/05/2013 | Page 2 of 6

Wild Collection Inventory 10.

Common Name

11.

12.

Number

Date

Collected Collected

13. Disposition

Code

14. Disposition

Date

Location of Collection

Education/Exhibition Report Form 2/05/2013 | Page 3 of 6

REPORT OF EXHIBITION ACTIVITIES

15. Name of Group or Individual

Address/location of Activity

Date of acitivity

Contact Telephone

16. NOTICE: Pursuant to ECL Section 3-0301(2)(Q) False statements made on this application are punishable pursuant to Section 210.45 of the New York State Penal Code.

Date

Signature of Licensee

Education/Exhibition Report Form 2/05/2013 | Page 4 of 6

INSTRUCTIONS y EDUCATION/EXHIBITION REPORT FORM

This form is to be used for all New York State Education/Exhibition licenses including: License to Collect or Possess, Endangered or Threatened Species Licenses, Reptile Exhibition Licenses, Dangerous Wildlife Licenses and Dangerous Fish Licenses.

Page 1 Licensee Information 1. Licensee's name, address and License type and number. 2. Licensee's date of birth. 3. Licensee's email address. 4. Telephone contact (Work, Home, Cell). 5. If applicable, please list business or organization name and address. 6. Facility Address - physical address where animals are housed.

Page 2 Captive Animal Inventory 7. List the common name, sex and age of each captive bred or permanently disabled animal held under this license during the past license year. 8. List the disposition code, date and name of the licensee or facility the animal was acquired from or transferred to (see disposition code table on page 6). 9. Indicate if the listed animal was used for exhibition during the license year.

Page 3 Wild Collection Inventory 10. List the common name of any specimens collected from the wild during the license year. 11. List the number of specimens collected. 12. List the date collections from the wild were conducted. 13. List the deposition code letter and date (see disposition code table on page 6). 14. List the location(s) where collection(s) were conducted.

Page 4 Report of Exhibition Activities 15. Complete the Report of Exhibition Activities by listing the group or individual, location, date(s) and phone number of where the activity was conducted. 16. Sign and date your report form.

Send the completed report to: NYS Department of Environmental Conservation y Special Licenses Unit y 625 Broadway y 5th Floor y Albany, NY 12233-4752

Education/Exhibition Report Form 2/05/2013 | Page 5 of 6

Disposition Code

Disposition Description

R

Retained: Previously held animals not acquired during the license year.

Captive Animal Disposition

A

T

Acquired: Animals acquired during the license year.

Transferred: Animals transferred to another licensee or facility during the license year.

D

Deceased: Animals that have died during the license year.

Enter the Corresponding disposition code in section 8 page 2 of the captive animal inventory

Disposition Code

Disposition Description

RT

Retained: Animals not released.

Wild Collection Disposition RL

Released: Animals released at the conclusion of activities.

M

Mortality: Animals that have died during sampling.

V

Voucher: Animals euthanized or salvaged as voucher specimens.

Enter the Corresponding disposition code in section 13 page 3 of the Wild Collection inventory.

Education/Exhibition Report Form 2/05/2013 | Page 6 of 6

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