2017 1004 ENR Wildlife Conservation License App
OFFICE USE ONLY
APPROVED
☐ DENIED ☐
APPLICATION #: ________ ISSUE DATE: ___________
WILDLIFE CONSERVATION LICENSE APPLICATION
This Application is submitted for the purpose of hunting or fishing on Osage Nation property. Approval is subject to review by the Director of the Department of Natural Resources (DNR). Submitting an application does not guarantee approval. The application must be completed and be returned to 100 West Main, Suite 304 Pawhuska, OK 74056. Applicants will be informed if they have been accepted within two (2) weeks of DNR receiving an application. I.
APPLICANT’S INFORMATION:
NAME: ______________________________________________
DATE OF BIRTH: _____________
ADDRESS: _________________________________________________________________________ CITY: _________________________________________________ STATE: ______ PHONE: ________________________
ZIP: _________
EMAIL: _______________________________________
DRIVER’S LICENSE NUMBER (PROVIDE ISSUING STATE): _____________________________________ *ATTACH COPY II. 1. 2. 3. 4. 5. 6. 7. 8. III.
PLEASE ANSWER THE FOLLOWING QUESTIONS: Are you a member of the Osage Nation? Are you a member of another tribe? (If yes, which one ______________________) Have you ever been convicted of a felony? Have you ever been convicted of violating any hunting or fishing law? Have you ever been cited for violation any hunting or fishing regulation? Do you have a current state or tribal issued hunting license? (If yes, attach copy) Do you have a current state or tribal issued fishing license? (If yes, attach copy) Do you have a lifetime hunting and fishing license? (If yes, attach copy) IDENTIFY LICENSE TYPE:
HUNTING
☐
FISHING
☐
BOTH
YES ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
NO ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
All Hunters are required to sign a Release and Waiver of Liability and Claims prior to entering upon the property of the Osage Nation to hunt or fish. By signing this Application, the undersigned acknowledges and agrees to abide by the Osage Nation Wildlife Conservation Act, applicable regulations, and Osage Nation law, and hereby consents to and submits to the exclusive jurisdiction of the Osage Nation Courts. Signature: _________________________________________________ Date: ________________
APPROVED
☐ DENIED ☐
APPLICATION #: ________ ISSUE DATE: ___________
WILDLIFE CONSERVATION LICENSE APPLICATION
This Application is submitted for the purpose of hunting or fishing on Osage Nation property. Approval is subject to review by the Director of the Department of Natural Resources (DNR). Submitting an application does not guarantee approval. The application must be completed and be returned to 100 West Main, Suite 304 Pawhuska, OK 74056. Applicants will be informed if they have been accepted within two (2) weeks of DNR receiving an application. I.
APPLICANT’S INFORMATION:
NAME: ______________________________________________
DATE OF BIRTH: _____________
ADDRESS: _________________________________________________________________________ CITY: _________________________________________________ STATE: ______ PHONE: ________________________
ZIP: _________
EMAIL: _______________________________________
DRIVER’S LICENSE NUMBER (PROVIDE ISSUING STATE): _____________________________________ *ATTACH COPY II. 1. 2. 3. 4. 5. 6. 7. 8. III.
PLEASE ANSWER THE FOLLOWING QUESTIONS: Are you a member of the Osage Nation? Are you a member of another tribe? (If yes, which one ______________________) Have you ever been convicted of a felony? Have you ever been convicted of violating any hunting or fishing law? Have you ever been cited for violation any hunting or fishing regulation? Do you have a current state or tribal issued hunting license? (If yes, attach copy) Do you have a current state or tribal issued fishing license? (If yes, attach copy) Do you have a lifetime hunting and fishing license? (If yes, attach copy) IDENTIFY LICENSE TYPE:
HUNTING
☐
FISHING
☐
BOTH
YES ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
NO ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
All Hunters are required to sign a Release and Waiver of Liability and Claims prior to entering upon the property of the Osage Nation to hunt or fish. By signing this Application, the undersigned acknowledges and agrees to abide by the Osage Nation Wildlife Conservation Act, applicable regulations, and Osage Nation law, and hereby consents to and submits to the exclusive jurisdiction of the Osage Nation Courts. Signature: _________________________________________________ Date: ________________
