APPLICATION Wildlife Collection License

Please complete this application in its entirety including providing necessary supplemental documentation. Failure to do so could result in the non-issuance of this license.

Revised 04/12

Part I: Applicant Information Applicant’s Name Telephone # ( )

(Last) (First) (M. Initial) Physical Address

(Street) (City) (State) (Zip Code)

Organization Affiliation (County) (Email)

Mailing Address (if different from above) (Street) (City) (State) (Zip Code)

Date of Birth Driver’s License #, State

Other individual assisting with permit activities (list all):

Part II: Permit Type: Endangered species permits may be needed in addition to the Wildlife Collection License issued for the research or possession of state or federally listed endangered, threatened, or special concern species in North Carolina for scientific or educational purposes only. Please indicate intended activity (Check all that apply)

Bird Banding * Commercial Use/Sale

Formal Education Research

Other

* A valid federal bird banding and marking permit must be obtained from the U.S. Geological Survey before a North Carolina wildlife collection license will be issued. Please include U.S.G.S. permit number here:

Part III: Species Information

Species (use scientific name or taxon) Quantity Location of Activity

** Attach additional pages as needed **

- Continued on Next Page -

APPLICATION Wildlife Collection License

Please complete this application in its entirety including providing necessary supplemental documentation. Failure to do so could result in the non-issuance of this license.

Revised 04/12

Continued

Part IV: Research

To conduct research on wildlife in North Carolina, individuals must submit a research proposal with this application, in hard copy or via email, at least two months prior to the start date of research activities. Applicants must also include their experience and/or qualifications to ensure the use of proper collection and handling methods. Please use the following checklist to make sure all items are addressed or included in the proposal:

Abstract Background Justification/need

Objectives/hypotheses Study design Study area*

Sampling period Sample size Collection methods

Data analysis methods Project time line Budget (draft or final)

Expected benefits or results Literature review Experience/qualifications

*The proposal must include a detailed map delineating the external boundaries of the study area and indicate specific collection sites within those boundaries.

Requested Start Date ___________________________________________________

Part V: NC Wildlife Commission Involvement

Will research activities occur on NCWRC game lands or other NCWRC owned property? Yes No

If yes, please list all NCWRC game lands or NCWRC property where activities will occur :

Will any aspect of the research require direct involvement by the Commission? Yes No

If yes, please check all that apply: Assessment of land management techniques

Collection activities or implementation Land management on game lands

Publication or review of manuscript(s) Project funding or budget analysis

Study design or data analysis Technical guidance

I hereby certify that all information contained herein is accurate and truthful to the best of my knowledge. I have read and understand the rules and statutes pertaining to the collection of wildlife in North Carolina, under 15A NCAC 10B.0119 and G.S. § 113-272.4, and agree to abide by these regulations. I understand that if I am issued a Wildlife Collection License I will be responsible for the humane and ethical treatment of all wildlife obtained under that license and that additional state licenses may be required for captivity. I also understand that the Commission may revoke my license at any time and confiscate all wildlife in my possession should I violate any of these regulations or the conditions listed on my license

Send completed application with a check or money order for $5.00 plus $2.00 for the

transaction fee made payable to NCWRC to: N.C. Wildlife Resources Commission

1707 Mail Service Center Raleigh, NC 27699-1707

1(888) 248-6834 www.ncwildlife.org

Applicant Signature Date

WRC USE ONLY Approved Denied

Permit Supervisor