Report created by RaptorMed (www.raptormed.com)

US FISH & WILDLIFE SERVICE - MIGRATORY BIRD PERMIT OFFICE

SPECIAL PURPOSE - POSSESSION FOR EDUCATION - ANNUAL REPORT
Office Use Only
Date completed report
received in
regional office
______/_____/_____

Initials: __________

PERMITEE:<>
<>
PERMIT NUMBER:<>
ADDRESS:<>REPORT FOR CALENDAR YEAR:<>
 REPORT DUE DATE: 
PHONE:<>EMAIL:<>

Check here if reporting a change in contact information [   ]

MAKE SURE YOU DATE AND SIGN THE CERTIFICATION STATEMENT BELOW BEFORE YOU SUBMIT YOUR REPORT.

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Species Live (L) or
Dead (D)
Date
acquired
Date
disposed
of
From whom acquired
or transferred to
Total
number
of programs
If on statc display,
the number of days
on display

CERTIFICATION: I certify that the information in this report is true and correct to the best of my knowledge. I understand that any false statements herein may subject me to the criminal penalties of 18 U.S.C. 1001.

Signature: __________________________ Date:   <>