Texas Parks & Wildlife Department



|[Dept. Use] Permit #: | |

|      |Application for Scientific Research Permit | |

|1. Applicant's Prefix (Mr., Ms., Miss, Mrs., Dr.): |      | | |Home Phone: |      |

|First Name: |      | |Office Phone: |      |

|Middle Name: |      | |Cell Phone: |      |

|Last Name: |      |Suffix: |      | |Fax Number: |      |

|Title: |      | |Date of Birth: |      |

|Profession: |      | |Driver's License No.: |      |

|Street Address: |      | |1 Social Security Number: |      |

| |      | |E-mail Address: |      |

|City: |      |State: |   |Zip: |      | |2nd E-mail Address: |      |

|2. Facility Name (business name): |      |

|Facility (physical) address: |      |

|City: |      |State: |   |Zip: |      |County: |      |

|3. Sub-permittees use PWD-0381A to list the name, driver's license # and state and telephone number of assistants whom you desire |Yes |   |No |   |

|to be named on your permit to work under your supervision. (Check if form is attached.) | | | | |

|4. Applicant is employed/ represents the following: |

| |(a) University or College |   |(e) Commercial Firm |   | |

| |(b) Federal Agency |   |(f) Non-Profit Organization |   | |

| |(c) State or Local Agency |   |(Please attach proof of non-profit status.) | |

| |(d) Public School System |   | | | |

|5. Briefly state educational and biological training (include degrees held): |

|      |

|6. Research Objective (in addition, please attach formal research proposal): |

|      |

|7. Justification for proposed activities: |

|      |

|8. Procedures [collection methods/devices (if applicable)]: |

|      |

1 Texas Parks and Wildlife Department maintains the information collected through this form. With few exceptions, you are entitled to be informed about the information we collect. Under Sections 552.021 and 552.023 of the Texas Government Code, you are also entitled to receive and review the information. Under Section 559.004, you are also entitled to have this information corrected.

   

|9. Research Location(s): |      |

|10. Projected Start Date: |      |Projected Completion Date: |      |

|11. Specimens will be disposed of as follows: |

|      |

|12. List specimens to be handled. If working with a large variety of organisms, list general categories (e.g., small mammals, birds, etc. ) Use an attachment if |

|necessary. List both common and scientific names. |

|Common Name |Scientific Name |Number of Specimens |

|      |      |      |

|      |      |      |

|      |      |      |

|      |      |      |

|      |      |      |

|13. Are any of the species you propose to handle/possess/collect, threatened or endangered: |Yes |   |No |   |

|Are any of the species protected by federal law that would otherwise restrict possession? |Yes |   |No |   |

|(i.e., migratory birds, federally listed threatened or endangered species, etc.) | | | | |

|14. Identify technical journals, bulletins or professional meetings/conferences where you intend to publish or present research findings. |

|      |

|15. Application must be accompanied by two letters of reference from experienced individuals in the appropriate biological or professional field for which the |

|applicant is applying.   |

|16. $53.00 Non-refundable Application Processing & Permit Fee enclosed: |Yes |   |*Exempt |   |

|*If exempt, you must complete and submit an exemption form PWD-0381B. Exemptions may only be granted to applicants meeting the criteria as stated in Texas Parks & |

|Wildlife TAC 31, § 69.310. |

| |

|It is my intention to collect and/or hold the number of specimens of the species indicated above for the purpose(s) stated. I hereby declare that the above |

|statements made by me are true and correct to the best of my knowledge, and I understand that making a false statement on this application or in subsequent annual |

|reports is a crime punishable by fine and/or imprisonment.     |

|I will submit a written report indicating the number and species of specimens collected and/or held during the reporting period, including specimens collected by |

|or held by my authorized co-permittees and sub-permittees. This report shall be received by the Texas Parks and Wildlife Department's Wildlife Permits Section |

|within 14 days after my renewal date each year.     |

| |

|  | |      |

|Signature of Applicant (Required) | |Date |

| |

|NOTE: This application will not be considered unless fully completed. Falsifying information on this document is a punishable offense.   Please Submit: A |

|complete and signed application, a research proposal detailing the use of protected wildlife, two letters of recommendation and the non-refundable $53.00 permit |

|fee (check or money order), attach any supplemental documentation (i.e., federal permits held, list of sub-permittees, etc.), and mail to:     |

| |

|Texas Parks & Wildlife Department |

|Wildlife Diversity Permits Section |

|4200 Smith School Road |

|Austin, TX 78744   |

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