Part 1.

Personal Data

Name

First

Middle Initial

Last

Date of Birth

Month

Day

Year

Social Security Number

Representing the following company, organization or governmental body (if applicable):

Address

Street

City

State

Zip Code

Phone

-

Area Code

Number

Part 2.

Type of permit applied for (check one):

Class A (Commercial)

Class B (Volunteer/Not-For-Profit Organizations*)

Class C (Governmental Bodies Only)

*

Not-for-Profit Organizations must attach a copy of their Internal Revenue Service tax-exempt status determination letter and a map or legal description of their properties where wildlife will be controlled

Part 3.

Work Area (Applicants for Class A and B Permits only)

A list of permittees is distributed to District Wildlife  Biologists and Conservation Police Officers so that they can refer complainants to permittees who service that area. Please list (in order of preference) up to four counties that you service. This list will be used strictly for referrals; your activities are not restricted to this area.

County 1

County 2

County 3

County 4

I certify that all information provided on this application is true and correct to the best of my knowledge. 

Applicant's Signature

RETURN COMPLETED APPLICATIONS TO:

Illinois Department of Natural Resources

Division of Wildlife Program Development and Coordination

One Natural Resources Way

Springfield IL  62702-1271