FORM 2723-A Revised 1/17 FOLE

FOR DEPARTMENT USE ONLY

Report ReceivedInspection completed

Date Received Region:

Date Review Complete Approved: Denied:

Valid From: To:

Approved By: Date:

ARIZONA GAME AND FISH DEPARTMENT WILDLIFE REHABILITATION LICENSE APPLICATION

R12-4-423

FEE: None Calendar Year[PLEASE PRINT OR TYPE]

NEW or RENEWAL

Name

City

Gender

Facility Address (if different than mailing)

Department ID Number or SSN: Date of Birth

State Zip Hair Weight Height Eyes

Phone

Number of Years ResidentResidentNon Resident

Email

or UTM Lat/Long

Mailing Address

For each location where wildlife will be held:(if other than your residence)

Organization Name

(decimal degrees only)

(if applicable)Website

StateCityMailing Address

Land Owners Name

Zip

Species held at this locationPhone

Lat/Long (decimal degrees only)

or UTM

Select all species you wish to rehabilitate. If not listed or if you do not wish to work with an entire group list the species under other.

Check All that Apply

AmphibiansReptilesBirds

Quail (order Galliformes)Dove (order Columbiformes)Hummingbirds (order Trochiliformes)Passerine birds (order Passeriformes) Raptors (orders Falconiformes or Strigiformes)Non-Passerine birds (birds not listed above)A Federal Rehabilitation

License is also required to work with Migratory birds and T&E species

MammalsNongame mammalsBats

Small GameCarnivoresBig Game (except cervids)

Other

USFWS Permit # Exp Date

FORM 2723-A Revised 1/17 FOLE

StateLicense #I am a licensed veterinarianI have a licensed veterinarian available to provide services when necessary

I affirm

Zip State City Clinic Address PhoneName of Veterinarian

List all individuals who will be applying to be an agent

StateCityMailing Address ZipPhone

Agent's Name Date of BirthAgent pre-approved

by Dept

Attachments: Additional information required under R12-4-423 (all documentation must by typed or legibly printed)

Provide documentation proving that you have one or more of the following: - a valid, current license to practice as a veterinarian; OR - a minimum of six months (8 hours or more per week) of applicable experience in wildlife rehabilitation; OR -a current state or Federal Wildlife Rehabilitation License. Documentation that proves a minimum of six months full time employment or volunteer experience handling the wildlife listed above. Include your experience training and experience handling, capturing, rehabilitating and caring for wildlife listed under section L(4).

Detailed description, diagram and photographs of facilities in which wildlife would be held (including the facilities of all agents please attach this information to the agent's application as well).

Describe how your's and your agent(s) facilities comply with captivity standards of R12-4-428. Include any additions or changes to facilities when submitting a renewal applications

Provide your preferred method of disposition of non-releasable wildlife.

Include a current copy of your federal permit and a copy of your approved agent list by USFWS

***RENEWAL APPLICATIONS MUST BE RECEIVED OR POSTMARKED BY DECEMBER 31st of every 3rd year ***

If this is a renewal application, a Wildlife Rehabilitation 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 year and the Department will not process this renewal application until the report(s) are received. Failure to report may result in a citation.

By signing above, I certify the information provided on this application is true and correct to my knowledge; I am applying for this license for the sole purpose of restoring wildlife to the wild through rehabilitative activities; you understand that all wildlife held under this license remains property of the state and shall be returned to the Department upon request; that I am solely responsible for all expenses incurred and all actions taken under the license, including all actions and omissions of all agents and assistants when they are performing activities authorized under the license; I shall conduct rehabilitation at the location listed above and I meet the criteria as outlined in R12-4-423 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.

Date Applicant Signature:

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 2723-A Revised 1/17 FOLE

Department Use OnlyFacility inspection completedPassed all needed exams within past 3 years

Raptor test Date Score

Yes NoYes NoYes No

Yes NoScoreDateSong bird test

ScoreDateMammal testCompleted 8 hrs Cont EdAnnual report(s) receivedHas Federal permit for Migratory birds

Must receive score of 80% or better to pass each exam

Other test ScoreDateYes No NumberApproved Agents