Fill and Sign the Student Employee Confidentiality Agreement Miami University Form

DIVISION OF WILDLIFE RESOURCES . 1594 West North Temple . Salt Lake City, UT 84114-6301 . (801) 538-4701 APPLICATION for Certificate of Registration (COR) FOR POSSESSION OF FALLOW DEER, CARIBOU (REINDEER) OR MUSKOX (R657-3) FILL OUT COMPLETELY AND LEGIBLY 1. Yes □ Initial Application No □ APPLICANT (name and complete address): 2. COMPLETE THE FOLLOWING FOR APPLICANT: Date of Birth Work Phone BUSINESS NAME/ADDRESS (if other than above): 3. Home Phone PURPOSE: TO OBTAIN FALLOW DEER, CARIBOU (REINDEER) OR MUSKOX FROM EITHER INSTATE OR OUT-OF-STATE SOURCES FOR (explain use in detail): PERSONAL, NON-COMMERCIAL USE (no breeding, selling, trading, bartering, exchanging) COMMERCIAL USE (breeding, selling, trading, bartering, exchanging) □ □ □ ______________________________ OTHER 4. SPECIFIC LOCATION(S) WHERE ANIMALS WILL BE HELD (Township, Range and Section information is available from the county recorder's office) (include attachment if requesting more than one location): 5. NAME AND COMPLETE ADDRESS OF SUPPLIER OF ANIMALS (the person from whom you are purchasing/trading/bartering animals instate must have a valid certificate of registration to do so: COUNTY: NAME: DRAINAGE: ADDRESS: CANYON: TOWNSHIP: RANGE: SECTION: COR # OF SOURCE IF OBTAINED INSTATE: STREET ADDRESS: _____________________________________ 6. Number NUMBER AND SPECIES: Species Name (common and scientific) 7. WHAT WILL BE THE FINAL DISPOSITION OF THE ANIMALS (keep till they die, sell, etc.): 8. REQUESTED BEGINNING AND ENDING DATES: 9. In many instances, other agency (federal/state/county/ city/municipal) laws covering live possession of animals or groups of animals, pond/facility location, water rights, etc. may be in effect. If local laws (city/county) restrict live possession of any zoological animal, written permission from the local entity granting authority to possess such animal must be submitted with this application for a COR. THE APPLICANT IS RESPONSIBLE FOR COMPLYING WITH SUCH LAWS PRIOR TO SUBMITTING A COR APPLICATION. If a federal permit is required for the activity applied for herein (U.S. Fish & Wildlife or U.S. Department of Agriculture), submit with this application either a copy of the permit or a copy of your application for the federal permit. 10. Enclosed is legal tender in the amount of $10.00 which is a nonrefundable handling fee. If your application is approved, additional fees may be billed. Make checks payable to: DIVISION OF WILDLIFE RESOURCES Submit application and nonrefundable handling fee to: WILDLIFE REGISTRATION OFFICE 1594 WEST NORTH TEMPLE, SUITE 2110 BOX 146301 SALT LAKE CITY, UT 84114-6301 Cashing your check or accepting money from you neither implies issuance or denial of a certificate of registration. I HEREBY CERTIFY THAT I HAVE READ AND AM FAMILIAR WITH THE RULES PERTAINING TO THE ACTIVITY(IES) APPLIED FOR AND THAT I ACCEPT ANY AND ALL LIABILITY RESULTING FROM THE ISSUANCE OF A CERTIFICATE OF REGISTRATION. I FURTHER CERTIFY THE INFORMATION SUBMITTED IN THIS APPLICATION FOR A COR IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND ANY FALSE STATEMENT HEREIN MAY RESULT IN THE APPLICATION BEING DENIED. __________________________________________________________ Applicant signature Date______________________________________________ __________________________________________________________ Parent signature if applicant is a minor