United States Department of the Interior U.S. FISH AND WILDLIFE SERVICE

Wertheim National Wildlife Refuge 340 Smith Road

Shirley, New York 11967 Voice: (631) 286-0485 Fax: (631) 286-4003

Dear Hunter, It is time to apply for the 2018-2019 deer hunts at Wertheim National Wildlife Refuge (refuge). Wertheim refuge is a 2,550 acre refuge located on Long Island’s south shore bisected by the Carmans River. The refuge hosts a variety of habitats including woodlands, grasslands, ponds, rivers and bays. Wertheim, a part of the Long Island National Wildlife Refuge Complex, is managed to protect the Carmans River estuary for use by migratory waterfowl and other waterbirds. The habitat is managed to maintain and enhance habitat, wildlife diversity and productivity. We look forward to a safe and productive hunting season. Please read all enclosed forms carefully. Please return your completed application(s) for the hunt(s) that you wish to apply for postmarked by or on August 31, 2018 to: Wertheim NWR Hunt 340 Smith Road Shirley, NY 11967 Re: Hunt Application and Exam For questions concerning the refuge deer hunt, contact our office between 8:30 am and 4 pm at 631-286-0485. Sincerely, Refuge Staff

2018–2019 Deer Hunting Wertheim National Wildlife Refuge

Hunter Orientation

Background Information Wertheim National Wildlife Refuge covers approximately 2,550 acres along the Carmans River. Approximately 1,600 acres of the refuge provide habitat for white-tailed deer (the remainder is primarily open water, salt marsh, and buildings/roads). Currently the refuge population ranges from 50 to 60 deer per square mile depending on the time of year and deer movement on and off the refuge. At higher densities, deer can over browse the available vegetation and, therefore, degrade habitat for other species. Deer-car collisions and deer browsing ornamental plantings in the adjacent residential areas become more serious problems at high deer densities. Our goal is to maintain the deer population at 20 to 30 deer per square mile and the ratio of antlerless to antlered deer at 3:1. The refuge seeks to offer a high quality hunting experience. Hunter numbers in the various units are low compared to many places on Long Island. For example, the refuge expects to have approximately one archer for every 40 acres. Application Information All hunters are required to complete the enclosed written orientation examination answer sheet and return it along with your hunt application to the refuge postmarked by August 31, 2018. The orientation exam can be taken only one time each year. All answers can be found in the material contained in this orientation packet. In addition to the New York State hunting license, all participating hunters must obtain a refuge permit. Refuge permits will be issued to those hunters that answer at least 90% of the orientation exam questions correctly (45 out of 50) and are selected during the hunt drawing. If you fail to score at least 90% on the written exam, or if you do not return your hunt orientation exam answer sheet, along with your hunt application, postmarked by August 31, 2018, your name will not be entered into the drawing to hunt on the refuge during the 2018 - 2019 deer season. Refuge permits are not transferable. Selected hunters who will not be attending their assigned hunt session must notify the refuge no less than one business day prior to the hunt session. Hunters who do not give proper notice will not be eligibility to participate in the deer hunt the following year. Additionally, permitted hunters are not allowed to bring friends or relatives with them during scouting or hunting days. However, youth hunters must be accompanied by a non-hunting adult who has a valid New York State hunting license during scouting and hunting. General Information The refuge is entirely within Suffolk County and the Town of Brookhaven. Please keep in mind

U.S. Fish and Wildlife Service

that other members of the public may be using the Carmans River during the hunting season. Extreme caution should be taken when hunting near the river. Refuge nature trails will be closed to non-hunters during the hunting periods. If you need to contact our office in case of an emergency, or to report a hunting violation, applicable phone numbers (Check Station: 631-316-3265) are on your refuge permit and contact card. Parking lots are assigned and refuge parking permits must be displayed face up on the dashboard of your vehicle. Hunters may not block access roads. Hunters are required to check in upon first entering the area each day and must check out before leaving at the end of each day. The refuge entrance gate and parking lots do not open until one hour before sunrise. Please do not block the refuge entrance gate or Smith Road. All hunting units on the refuge will be open for scouting between 8:00 a.m. and 4:00 p.m. for selected archery hunters on October 27 and November 24, and for selected shotgun hunters on December 29. Please obey the posted speed limits on the roads. During scouting, hunters must park in designated parking areas (with their refuge parking permit displayed face up on the vehicle dashboard). Hunters must hold a refuge hunting permit in order to scout. Any vehicles parked illegally will be ticketed and towed if necessary. While you may scout any unit, we encourage you to first scout the unit you are assigned to. Hunters must carry their New York State hunting license and refuge hunting permit with them during scouting days. As a reminder for hunters in tree stands, the first thing you should do upon entering a portable tree stand is to fasten your safety harness. The refuge encourages hunting from tree stands because it provides a safer shooting angle and better visibility. Hunters must remove their tree stand at the end of the hunt session. The refuge also asks that hunters demonstrate courtesy by not setting up close to another hunter, and not dressing harvested deer in refuge parking lots or along refuge trails. Additionally, transporting harvested deer uncovered, and in plain view of the public (such as on the hood of your car or uncovered on a trailer hitch cargo rack) does not promote ethical hunting and may foster opposition to deer hunting in the surrounding communities. The refuge encourages hunters to be respectful of the non-hunting public and be good ambassadors of their sport. During the refuge shotgun sessions, the southern portion of unit 3 and all of unit 5 will be closed to hunting. These areas are located on the enclosed hunt map. The southern portion of Unit 3 will be marked using red and white striped flagging. Property located south of the red and white flagging is not open to shotgun hunting. Hunters are responsible for identifying their target before they shoot. It is recommended that hunters do not try to shoot a deer on the run to prevent inflicting a non-fatal wound. If you shoot a deer, you must make every effort to locate it and reduce it to possession. Standby Hunting We will continue using the expanded pool of potential standby hunters. Hunters who submit their complete hunt application by August 31, 2018, AND successfully pass the written orientation exam (at least 90%), will be eligible to participate as a standby hunter. All hunters who applied for an archery permit and successfully passed the orientation exam (at least 90%) will be eligible

to participate as standby hunters during any of the archery sessions. All hunters who applied for a shotgun permit and successfully passed their orientation exam (at least 90%) will be eligible to participate as standby hunters during any shotgun session. To avoid parking lot congestion during scouting days, only hunters selected for a hunt session will be allowed to scout. The sale of permits after the drawing has been discontinued. All hunters must apply by the deadline, August 31, 2018. Standby hunters may arrive at the Wertheim hunter check station one hour before sunrise. Standby hunters present at the check station will be randomly selected to fill any known openings at this time. One hour after sunrise, standby hunters present at the check station will be randomly selected to fill any remaining empty slots. Standby hunters not selected at the sunrise drawing may continue to wait in the check station parking area. As hunters leave for the day, their slots will be randomly filled from the standby hunters present. A standby hunter, who is granted permission to hunt on the first day of a hunt session, will still be a standby hunter on the second day and must wait to be selected before hunting. Regulations for 2018 – 2019 Deer Hunting

1. Hunters must check in at the refuge check station at the beginning of each hunt day and check out at the end of each hunt day, even if no deer were harvested. Hunters who have not checked in by one hour after sunrise risk losing their spot and may be ineligible to hunt during the following season.

2. Hunters may enter the refuge no earlier than one hour before the beginning of legal

shooting hours and must exit the refuge no later than one hour after the end of legal shooting hours. If you have a deer down and are not able to get it out of the woods before sunset, you must call the Refuge Check Station.

3. The bag limit for both the archery and shotgun sessions is three deer per hunter. Hunters

may take either one or two antlerless deer before taking an antlered deer. Hunters who take one antlerless deer then one antlered deer may take another antlerless deer, if time permits. Hunters may choose to take three antlerless deer and forfeit their opportunity to take an antlered deer. Antlerless deer must be checked in at the refuge check station prior to shooting an antlered deer. The Refuge does not provide New York State carcass tags. Be sure to supply your own NYS tags for the deer you harvest.

4. Hunters can take up to two antlerless deer before checking them in at the refuge deer

check station (an antlerless deer is defined as any deer with no antlers or both antlers less than three inches in length).

5. All deer harvested on the refuge must be checked in at the official refuge deer check

station. Hunters are also responsible for following New York State hunting regulations for checking in deer with the State.

6. Upon kill, hunters must complete a New York State carcass tag for each deer. Tags must be attached to deer after hunters reach their vehicle. If you fail to follow these procedures, you will be in violation of both Federal and State hunting laws.

7. Hunters must tag all deer with New York State issued hunting tags.

8. Upon checking in at least one antlerless deer at the refuge check station, you will be

issued a refuge buck slip. This buck slip allows you to harvest one antlered deer on Wertheim National Wildlife Refuge. The buck slip will be valid for the remainder of the hunt. Please note that buck slips issued during the archery season will not be valid during the shotgun season. To be eligible to shoot a buck on refuge property you must also possess a New York State issued antlered deer tag.

9. A hunter without a refuge buck slip cannot shoot a buck and use someone else’s buck slip and permit to tag it.

10. The refuge does not permit the marking of any tree, trail, or other refuge feature with

flagging, paint, reflective material, or any other substance.

11. Hunters may trim branches up to the diameter of a quarter to place tree stands.

12. Distribution of bait and the hunting over bait is prohibited on the refuge.

13. Hunters may NOT push or drive deer.

14. Only barbless broadheads are permitted during the archery season. Please refer to the current New York State Hunting and Trapping Regulations handbook for more details.

15. Only shotguns firing a single projectile (slugs only, no buckshot) are permitted during

firearm season. Muzzle loaders are not permitted on the refuge.

16. Hunters must have only shotgun shells loaded with slugs during the shotgun season.

17. Shotgun hunters must wear in a conspicuous manner on HEAD, CHEST, and BACK a minimum of 400 square inches of SOLID FLOURESCENT ORANGE clothing. Camouflage Orange alone is NOT permitted.

18. Each hunter may only use one portable deer tree stand and it may be left on the refuge

during your designated hunt period at your own risk. Hunters must attach clearly legible identification on their stands with their name, address, and phone number. The refuge will not be responsible for any stolen property. Tree stands must be removed from the hunt unit at the end of the hunt session.

19. Hunters selected to hunt in unit 5 MUST hunt from a portable tree stand. Unit 5 is for

Archery hunters only.

20. You must use a safety harness and belt while hunting from a tree stand.

21. Hunt unit 4 has special access for Disabled Hunters Only at the White Oak Nature Trail.

Hunters must carry a refuge hunt permit before entering this area. Only hunters possessing a state-issued “Permit for Physically Challenged Hunters” are eligible to receive special access to this area. Contact the refuge office for details, 631-286-0485.

22. Individuals utilizing the refuge are subject to inspections of permits, licenses, hunting equipment, bag limits, boats, vehicles, and their contents by Federal and/ or State Law Enforcement Officers.

23. Hunters may not have loaded weapons (including nocked arrows) in the 500-foot no hunt

buffer zone (shaded in red on the Refuge hunting map).

24. The sign below marks the no hunting buffer (safety zone) on the refuge. Along with the signs, there is purple blazing on trees placed between the signs to help mark the safety zone boundary. Hunters are responsible for knowing where they are at all times in relation to hunting zones and refuge boundaries.

25. Below on the left is a sign with the National Wildlife Refuge System’s blue goose

symbol. That sign is used to mark the refuge boundaries. On the right, the “Area Beyond This Sign Closed,” is a refuge sign that can only be ignored during designated scouting days and hunting sessions.

REFUGE BOUNDARY SIGN AREA CLOSED SIGN Additional Prohibited Activities

• Littering • Use of a spotlight or other artificial light may not be used to locate wildlife

• Baiting or hunting over bait, salt, or any attractant • Driving or screwing a nail, spike, or other metal object into a tree or hunting from any

tree in which such an object has been driven • Use or possession of alcoholic beverages • Use of ATVs and/or dirt bikes, or other non-licensed vehicles • Target practice • Camping and campfires • Overnight parking • Searching or removing objects of antiquity including arrowheads, pottery or other items • Searching for or removing plants or animals other than deer from the refuge • Blocking gates or roadways with vehicles • Pets are not permitted on the refuge at anytime

Remember, while hunting on the refuge, you are responsible for knowing and abiding by all State, Federal, and Refuge regulations. Know where you are at all times and respect private property. Violators may lose all future privileges to hunt on federal property throughout the United States. Application Instructions

To ensure your application is fully completed and submitted properly, please review the following instructions: Fill out name, address, phone number and email information neatly and completely on the . If you

are selected to hunt on the refuge, the contact information on your application will be used to notify you, so please print legibly.

Complete Hunter Orientation Exam Answer Sheet ONLY and attach it to your hunt

application. If you would like to apply as a pair, please write in “Paired with” followed by your hunting

partner’s name in the top margin of your application. BOTH applicants in the pair must fill out all application materials individually (including the Application Exam and payment). Paired applications must be submitted in the same envelope. Applications received separately will not be paired.

Hunt unit 4 meets the Americans with Disabilities Act (ADA) accessibility requirements. Circle

Box # 7 on the hunt application form if you possess a state-issued “Permit for Hunter with Disability” and you are interested in being assigned to this unit if selected.

Archery hunters are required to use portable tree stands in hunt unit 5. If you are unwilling or

unable to hunt from a tree stand, please consider this when ranking your hunt unit preferences. Please rank the archery hunt sessions in order of preference. The dates are as follows: Archery 1;

November 2 – 3, 2018 (2 days), Archery 2; November 29 – December 1, 2018 (3 days), and Archery 3; December 14 – 15, 2018 (2 days). During the drawing, you will be assigned to your preferred period if slots are available. Upon successful completion of your orientation exam, you will be eligible to participate in any archery session as a standby hunter.

Please rank the hunt units in order of preference. During the drawing, you will be assigned to your

preferred hunt unit if slots are available.

Please rank the shotgun hunt sessions in order of preference. The dates are as follows: Shotgun 1; January 7 - 8, 2019 (2 days) and Shotgun 2; January 16 - 17, 2019 (2 days). During the drawing, you will be assigned to your preferred period if slots are available. Upon successful completion of your orientation exam, you will be eligible to participate in any shotgun session as a standby hunter.

Please rank the hunt units in order of preference. During the drawing, you will be assigned to

your preferred hunt unit if slots are available. The application fee is $15.00 per application. This is an administrative fee that is non-refundable,

even if you are not selected to hunt. Please include a check or money order payable to the U.S. Fish and Wildlife Service with your application package.

Applications must be postmarked or returned to the refuge by August 31, 2018. Late and/or

incomplete applications will not be accepted. Results of the drawing for hunt permits will be available on October 5, 2018.

All applicants will be notified by mail with the drawing results.

Hunters age 16 or 17 may be accompanied by a licensed non-hunting adult if desired.

Hunters under age 16 must be accompanied by a licensed non-hunting adult.

Wertheim National Wildlife Refuge 340 Smith Road Shirley, NY 11967 Re: Hunt Application and Exam If you have any questions, please contact the refuge office at 631-286-0485, Monday through Friday, 8:00 a.m. to 4:00 p.m.

SUBMIT YOUR HUNT APPLICATION NO LATER THAN AUGUST 31, 2018.

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WERTHEIM NWR 2018-2019 HUNTER ORIENTATION EXAMINATION Complete Answer Sheet ONLY. Return answer sheet with hunt application.

1. Are you permitted to push or drive deer from a safety zone? YES NO 2. Any hunter not planning to attend their designated hunt session must notify the refuge at least 1

business day prior to the hunt. Failure to adhere to this policy will result in that hunter’s ineligibility to participate in the hunt the following year.

TRUE FALSE 3. Hunters may use a temporary or portable tree stand and must:

a. Leave it on the refuge b. Leave it at the base of the tree for the night c. Remove it at the end of your assigned hunt session d. All of the above

4. Are you allowed to hunt on Wertheim NWR property if you do not receive a score of 90% or higher on this written examination? YES NO

a. 5. Your parking permit must be displayed face up in a readable fashion on your vehicle

dashboard. TRUE FALSE

6. Hunters who harvest at least one doe 1.5 years or older will be issued a special refuge buck slip that will be valid for the rest of the hunting season.

TRUE FALSE 7. How many antlerless deer must you shoot before taking an antlered deer?

a. None b. One c. Two d. Three

8. Within the 500 foot No Hunt Buffer the following is prohibited: a. Carrying a loaded weapon b. Discharging a weapon c. Driving or pushing deer d. All of the above

9. Archery hunters assigned to unit five (5) must hunt from a portable tree stand and must direct aim away from a public road and/or dwelling

TRUE FALSE 10. Upon shooting and downing a deer you must:

a. Fill out a NY state hunting carcass tag b. Fill out a refuge hunting carcass tag c. Do nothing d. Wait until a you shoot another deer

11. You are allowed to mark any tree, trail, or other refuge feature with flagging, paint, reflective material or any other substance.

TRUE FALSE 12. Youth hunters must always be under immediate supervision of a non-hunting, licensed adult.

TRUE FALSE

13. Do the buck tags that are attached to your hunting license entitle you to shoot a buck at Wertheim NWR? YES NO

14. Hunters may drive directly to refuge parking lots without first checking in; however, they should wait until 1 hour before legal hunting time.

TRUE FALSE 15. While hunting at Wertheim NWR, you are not allowed to:

a. Drive or push deer b. Shoot a buck and use your friend’s refuge buck permit c. Shoot wildlife other than deer d. All of the above

16. Hunters must check in and check out each day even if no deer were harvested. TRUE FALSE

17. If you get sick and are unable to hunt during your assigned hunting session, you can give your refuge hunting permit to a friend and allow them to hunt in your place.

TRUE FALSE 18. During scouting days, you are not allowed to bring a friend or family member with you that did

not apply for the hunt. TRUE FALSE

19. Hunters will be issued a permit to shoot an antlered deer only after they have checked in one antlerless deer.

TRUE FALSE 20. The first thing you must do after entering an elevated tree stand is:

a. look around for deer b. haul up your unloaded gun c. attach your safety harness d. check wind direction

21. Hunters are allowed to enter the refuge 1 hour before legal hunting hours and must leave the refuge no later than 1 hour after legal sunset.

TRUE FALSE 22. If you get a refuge deer, are you required to check it in at the refuge check station?

YES NO 23. Is it permitted to use or construct a permanent tree stand or install a nail, spike, or other metal

object into any tree on the refuge? YES NO 24. What is the color of the safety zone blazes?

a. Red b. Blue c. Purple d. Orange with black stripes

25. You are allowed to trim or cut branches: a. Smaller than a quarter in diameter b. Larger than a quarter in diameter c. Whatever size you want d. You are not allow to cut any branches

26. All archery applicants who pass their exam will be eligible to participate as standby hunters during all archery sessions. All shotgun applicants who pass their exam will be eligible to participate as standby hunters during all shotgun sessions. TRUE FALSE

27. During the refuge shotgun season hunters are required to wear:

a. A minimum of 400 square inches of solid orange clothing b. A minimum of 200 square inches of solid orange clothing c. No orange clothing is required d. An orange hat

28. Does hunting from a tree stand provide a safer shooting angle and better visibility? YES NO

29. Hunters must attach their name, address, and phone number to their portable tree stands. TRUE FALSE

30. Is the use or possession of alcoholic beverages allowed while hunting? YES NO 31. Hunters must limit driving to designated access roads and park only in designated areas.

TRUE FALSE 32. Muzzleloaders, in addition to shotguns, are permitted during the refuge hunt.

TRUE FALSE 33. Hunters will be checked for valid permits, licenses, hunting equipment etc. by Federal

and/ or State Law Enforcement Officers. TRUE FALSE 34. What time must hunters check in by at the check station on hunt days?

a. Sunrise b. 8:30 am c. One hour after Sunrise d. There is no check in time

35. Hunters may bring dogs onto the refuge to assist in pushing or driving deer. TRUE FALSE

36. Is it courteous to hunt close to another hunter? YES NO 37. Distribution of bait and the hunting over bait are permitted on the refuge.

TRUE FALSE 38. The bag limit is unlimited antlerless deer per hunting session.

TRUE FALSE 39. An antlerless deer is defined as any deer with no antlers or both antlers less than three inches in

length. TRUE FALSE

40. During shotgun season you must only have in your possession shotgun shells loaded with buckshot.

TRUE FALSE 41. To avoid wounding deer, it is recommended that you not shoot at deer that are on the run.

TRUE FALSE 42. What color is the safety zone marked on the refuge hunt map?

a. Red crosshatch b. Blue dots c. White d. Orange with black stripes

43. Hunters are allowed to dress their deer in the refuge parking areas and along trails. TRUE FALSE

44. Wertheim NWR will issue you a state carcass tag if you need one on the day of your assigned hunt? TRUE FALSE

45. If you violate refuge hunting regulations, you may lose the privilege to hunt on all federal property in the future.

TRUE FALSE 46. If you down a deer at sunset, you are allowed to continue looking for it beyond legal hunting

hours without notifying the deer check station. TRUE FALSE

47. Which of the signs below is used to mark the refuge’s boundary? A B C 48. Which sign below is an internal refuge sign that you can only walk past on the designated

scouting days and during refuge hunting sessions? A B C 49. Which sign below is used to mark the no hunt buffer zone (safety zone)? A B C

A B C 50. What County is Wertheim NWR in?

a. Nassau b. Suffolk c. Brookhaven d. Queens

Exam Answer Sheet Please return ONLY the ANSWER SHEET

Name of Applicant Signature

By signing this exam, you are stating that you have read and understand the information enclosed in the Wertheim NWR hunter orientation packet. Please return your completed orientation exam answer sheet and hunt application no later than August 31, 2018 to:

Wertheim NWR 340 Smith Rd Shirley, NY 11967 Attn: Hunt Application and Exam

1. 20. 39.

2. 21. 40.

3. 22. 41.

4. 23. 42.

5. 24. 43.

6. 25. 44.

7. 26. 45.

8. 27. 46.

9. 28. 47.

10. 29. 48.

11. 30. 49.

12. 31. 50.

13. 32.

14. 33.

15. 34.

16. 35.

17. 36.

18. 37.

19. 38.

Hunter with Disability

Wertheim National Wildlife Refuge

U.S. Fish and Wildlife Service Quota Deer Hunt Application National Wildlife Refuge System Follow instructions in the refuge hunt publication; all fields may not be required. Read and comply with all refuge regulations, including application deadlines.

OMB Control Number 1018-0140 Expires 05/31/2018

1. Name of Refuge 2. Date of application

3. Legal Name Area Code/Phone No.

Mailing Address

City, State, ZIP e-mail

4. Method

5. Hunt Date Choice 1st Choice 6. Hunt Location Choices 1st Choice

2nd Choice

3rd Choice

4th Choice

5th Choice

2nd Choice

3rd Choice

4th Choice

5th Choice

7. Special Hunt 7A. Youth Hunt Only: Age at time of hunt

8. I have read and understand the refuge hunt regulations and agree to abide bythe regulations governing hunting on the refuge.

Hunter signature Print Guardian name andsignature here(required for hunters less than 18 years of age)

For Office Use only:

Payment Exempt/No fee Payment required

Payment Type:

Personal Check

Amount:

CashiersCheck Notes

Money Order Other

Notice In accordance with the Privacy Act (5 U.S. C. 552a) and the Paperwork Reduction Act (44 U.S. C. 3501), please note the following information: 1. The issuance of a permit and collection of fees on lands of the National Wildlife Refuge System is authorized bythe National Wildlife Refuge System Administration Act (16 U.S. C. 668dd-ee) as amended, and the Refuge Recreation Act (16 U.S. C. 460k-460k-4). 2. The information that you provide isvoluntary; however submission of requested information isrequired to evaluate the qualifications, determine eligibility, and document permit applicants under the above Acts. It is our policy not to use your name or email for any other purpose. Theinformation ismaintained in accordance with the PrivacyAct. All information you provide will be considered inreviewingthisapplication. False, fictitious, orfraudulent statements or representations madein the application maybegroundsfor revocation of the permit and maybe punishable byfine or imprisonment (18 U.S.C. 1001). Failure to provide all required information is sufficient cause for the U.S. Fish and Wildlife Service to deny a permit. 3. Weestimate the public reporting burden on the applicant for information collection to be 30 minutes. Thisburden estimate includes time for reviewing instructions, gathering and maintaining data and completing and reviewing the form. You may direct comments regarding the burden estimate or any other aspect of the form to the Service Information Clearance Officer, U.S. Fish and Wildlife Service, Mail Stop BPHC, U.S. Department of the Interior, 1849 C Street, NW, Washington D.C. 20240. 4. Routine usedisclosures may be made: (a)to the U.S. Department of Justicewhen related to litigation oranticipatedlitigation; (b) of information indicatinga violation or potential violation of a statute, rule, order, or license to appropriate Federal, State,local orforeign agenciesresponsible for investigating or prosecuting the violationor for enforcing or implementing the statute, rule, regulations, order, orlicense; (c)from the recordoftheindividualin responseto aninquiryfrom aCongressional office made attherequest oftheindividual(42 FR19083;April11, 1977);and (d)to provide addressesobtained from the Internal Revenue Serviceto debt collection agenciesfor purposes of locating adebtor to collect orcompromise a Federal Claim against the debtor, orto consumer reporting agencies to prepare a commercial credit report for use by the Department (48 FR 54716; December 6, 1983). 5. An agencymaynot conduct orsponsor, and aperson isnot required to respondto acollection ofinformation unlessit displays acurrently valid OMB control number. Thisinformationcollection has been approved by OMB and assigned control number 1018-0140.

FWS Form 3-2354 REV 05/15

PRINT FORM

Date Received

n/a

Archery

n/a

Hunter with Disability

Wertheim National Wildlife Refuge

U.S. Fish and Wildlife Service Quota Deer Hunt Application National Wildlife Refuge System Follow instructions in the refuge hunt publication; all fields may not be required. Read and comply with all refuge regulations, including application deadlines.

OMB Control Number 1018-0140 Expires 05/31/2018

1. Name of Refuge 2. Date of application

3. Legal Name Area Code/Phone No.

Mailing Address

City, State, ZIP e-mail

4. Method

5. Hunt Date Choice 1st Choice 6. Hunt Location Choices 1st Choice

2nd Choice

3rd Choice

4th Choice

2nd Choice

3rd Choice

4th Choice

5th Choice

7. Special Hunt 7A. Youth Hunt Only: Age at time of hunt

8. I have read and understand the refuge hunt regulations and agree to abide bythe regulations governing hunting on the refuge.

Hunter signature Print Guardian name and signature here(required for hunters less than 18 years of age)

For Office Use only:

Payment Exempt/No fee Payment required

Payment Type:

Personal Check

Amount:

Cashiers Check Notes

Money Order Other

Notice In accordance with the Privacy Act (5 U.S. C. 552a) and the Paperwork Reduction Act (44 U.S. C. 3501), please note the following information: 1. The issuance of a permit and collection of fees on lands of the National Wildlife Refuge System is authorized bythe National Wildlife Refuge System Administration Act (16 U.S. C. 668dd-ee) as amended, and the Refuge Recreation Act (16 U.S. C. 460k-460k-4). 2. The information that you provide isvoluntary; however submission of requested information isrequired to evaluate the qualifications, determine eligibility, and document permit applicants under the above Acts. It is our policy not to use your name or email for any other purpose. Theinformation ismaintained in accordance with the PrivacyAct. All information you provide will be considered inreviewingthisapplication. False, fictitious, orfraudulent statements or representations madein the application maybegroundsfor revocation of the permit and maybe punishable byfine or imprisonment (18 U.S.C. 1001). Failure to provide all required information is sufficient cause for the U.S. Fish and Wildlife Service to deny a permit. 3. Weestimate the public reporting burden on the applicant for information collection to be 30 minutes. Thisburden estimate includes time for reviewing instructions, gathering and maintaining data and completing and reviewing the form. You may direct comments regarding the burden estimate or any other aspect of the form to the Service Information Clearance Officer, U.S. Fish and Wildlife Service, Mail Stop BPHC, U.S. Department of the Interior, 1849 C Street, NW, Washington D.C. 20240. 4. Routine usedisclosures may be made: (a)to the U.S. Department of Justicewhen related to litigation oranticipatedlitigation; (b) of information indicatinga violation or potential violation of a statute, rule, order, or license to appropriate Federal, State,local orforeign agenciesresponsible for investigating or prosecuting the violationor for enforcing or implementing the statute, rule, regulations, order, orlicense; (c)from the recordoftheindividualin responseto aninquiryfrom aCongressional office made attherequest oftheindividual(42 FR19083;April11, 1977);and (d)to provide addressesobtained from the Internal Revenue Serviceto debt collection agenciesfor purposes of locating adebtor to collect orcompromise a Federal Claim against the debtor, orto consumer reporting agencies to prepare a commercial credit report for use by the Department (48 FR 54716; December 6, 1983). 5. An agencymaynot conduct orsponsor, and aperson isnot required to respondto acollection ofinformation unlessit displays acurrently valid OMB control number. Thisinformationcollection has been approved by OMB and assigned control number 1018-0140.

FWS Form 3-2354 REV 05/15

PRINT FORM

Date Received

n/a

Shotgun

n/a

n/a