Form 2721-B

ARIZONA GAME AND FISH DEPARTMENT

WILDLIFE SERVICE LICENSE REPORT R12-4-421 FOR DEPARTMENT USE ONLY

DUE NO LATER THAN JANUARY 31 REPORT FOR CALENDAR YEAR

Date Received

Region:

Name Wildlife Service License Number Email Address Service Date

Location of Service

Signature

This report must be submitted regardless of whether or not activities were performed during the previous year. Failure to submit a report may result in a citation # of Wildlife handled

Species Removed

Date Released

Location Released

Euthanized when authorized

Reason for Euthanasia

Date

By signing this document I affirm that the information provided on this report is true and accurate. This report is due to the Arizona Game and Fish Department's regional office that issued your license by Jan. 31 following the license year. Form 2721-B Revised 1/17 FOLE

Name

License Number

ARIZONA GAME AND FISH DEPARTMENT

WILDLIFE SERVICE LICENSE REPORT Continuation Form Service Date

Location of Service

Signature

# of Wildlife handled

Species Removed

Date Released

Location Released

Date

Euthanized when authorized

By signing this document I affirm that the information provided on this report is true and accurate.

Form 2721-B Revised 1/17 FOLE

Reason for Euthanasia