Form 2721-A
ARIZONA GAME AND FISH DEPARTMENT WILDLIFE SERVICE LICENSE APPLICATION R12-4-421
FOR DEPARTMENT USE ONLY
Date Received
Region:
Date Review Complete
Approved:
Valid
From:
To:
Approved By:
Report Received
Date:
FEE: None
[PLEASE PRINT OR TYPE]
NEW
Denied:
Calendar Year
or
RENEWAL
Department ID Number or SSN: Name
Date of Birth
Mailing Address City Gender
State
Zip
Height
Weight
Hair
Phone Eyes
______ Number of Yrs Resident Resident Non Resident Physical Address (if different than mailing) Email Business Name Business Mailing Address City
State
Business Phone number DAYS
Zip NIGHTS
Federal Tax ID # (If for commercial purposes) If this is for commercial use list below the hours and days your business will be available to provide this service.
Days of the week
Check All that Apply
Hours of Operation Furbearing (raccoons, weasels, bobcats) Non-game (jackrabbits, bats) Predatory (foxes, skunks, coyotes, bobcats) Small game (cottontails,tree squirrels) When acting as an agent of a property owner or mgr who possesses an appropriate permit.
Others (list below)
FORM 2721-A Revised 1/17 FOLE
Javelina Skunks AZ reptiles Migratory Birds when acting as an agent of a property owner or manager who possesses appropriate U.S. Fish and Wildlife Service permits if necessary
List all methods of capture and removal
Geographic area of Service
Attachments: Additional information required under R12-4-421 Written narrative explaining applicant's experience in the capture, handling and removal of wildlife, specifying all species for which you have performed such function, referencing the general location and dates that such services were performed, methods used to carry out the activities and methods of disposition for the wildlife captured. Documentation that proves a minimum of six months full time employment or volunteer experience handling the wildlife listed above. Annual report is required to be submitted by January 31st of the following year even if you are not renewing your license. Failure to submit may result in a citation. ***RENEWAL APPLICATIONS MUST BE RECEIVED OR POSTMARKED BY DECEMBER 31st *** If this is a renewal application, a Wildlife Service license holder shall submit an annual report to the Department for activities performed under the license for the previous calendar year. The reports must be submitted regardless whether or not work was performed during the year. The license becomes invalid if the report is not submitted by January 31st of the following yearand the Department will not process this renewal application until the report is received. Failure to report may result in a citation.
Applicant Signature:
Date
I certify the information provided on this application is true and correct to my knowledge. I will comply with any municipal, county, state, or federal code, ordinance, statute, regulation or rule applicable to this license and that my live wildlife privileges are not currently suspended or revoked in this state, any other state or territory, or by the United States. In accordance with provisions under Section 41-1030, Arizona Revised Statutes: An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by a statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or condition. This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable attorney fees, damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section. A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal pursuant to the Agency's adopted personnel policy. This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.
FORM 2721-A Revised 1/17 FOLE
FOR DEPARTMENT USE ONLY
Date Received
Region:
Date Review Complete
Approved:
Valid
From:
To:
Approved By:
Report Received
Date:
FEE: None
[PLEASE PRINT OR TYPE]
NEW
Denied:
Calendar Year
or
RENEWAL
Department ID Number or SSN: Name
Date of Birth
Mailing Address City Gender
State
Zip
Height
Weight
Hair
Phone Eyes
______ Number of Yrs Resident Resident Non Resident Physical Address (if different than mailing) Email Business Name Business Mailing Address City
State
Business Phone number DAYS
Zip NIGHTS
Federal Tax ID # (If for commercial purposes) If this is for commercial use list below the hours and days your business will be available to provide this service.
Days of the week
Check All that Apply
Hours of Operation Furbearing (raccoons, weasels, bobcats) Non-game (jackrabbits, bats) Predatory (foxes, skunks, coyotes, bobcats) Small game (cottontails,tree squirrels) When acting as an agent of a property owner or mgr who possesses an appropriate permit.
Others (list below)
FORM 2721-A Revised 1/17 FOLE
Javelina Skunks AZ reptiles Migratory Birds when acting as an agent of a property owner or manager who possesses appropriate U.S. Fish and Wildlife Service permits if necessary
List all methods of capture and removal
Geographic area of Service
Attachments: Additional information required under R12-4-421 Written narrative explaining applicant's experience in the capture, handling and removal of wildlife, specifying all species for which you have performed such function, referencing the general location and dates that such services were performed, methods used to carry out the activities and methods of disposition for the wildlife captured. Documentation that proves a minimum of six months full time employment or volunteer experience handling the wildlife listed above. Annual report is required to be submitted by January 31st of the following year even if you are not renewing your license. Failure to submit may result in a citation. ***RENEWAL APPLICATIONS MUST BE RECEIVED OR POSTMARKED BY DECEMBER 31st *** If this is a renewal application, a Wildlife Service license holder shall submit an annual report to the Department for activities performed under the license for the previous calendar year. The reports must be submitted regardless whether or not work was performed during the year. The license becomes invalid if the report is not submitted by January 31st of the following yearand the Department will not process this renewal application until the report is received. Failure to report may result in a citation.
Applicant Signature:
Date
I certify the information provided on this application is true and correct to my knowledge. I will comply with any municipal, county, state, or federal code, ordinance, statute, regulation or rule applicable to this license and that my live wildlife privileges are not currently suspended or revoked in this state, any other state or territory, or by the United States. In accordance with provisions under Section 41-1030, Arizona Revised Statutes: An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by a statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or condition. This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable attorney fees, damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section. A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal pursuant to the Agency's adopted personnel policy. This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.
FORM 2721-A Revised 1/17 FOLE
