"Falconry Permit Application (11 - Falc)" - Virginia

Falconry Permit Application (11 - Falc) is a legal document that was released by the Virginia Department of Wildlife Resources - a government authority operating within Virginia.

Form Details:

  • Released on September 29, 2020;
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Download "Falconry Permit Application (11 - Falc)" - Virginia

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VIRGINIA DEPARTMENT OF WILDLIFE RESOURCES
AND U. S. FISH AND WILDLIFE SERVICE
FALCONRY PERMIT APPLICATION (11 – FALC)
Under State Authority of §29.1-412, §29.1-419, Code of Virginia, 4 VAC 15-250
Under Federal Authority of 16 U.S.C. 701-712 and 50 C.F.R. §§13, 21.28, 21.29
State Fee (Non-Refundable) and Type of Permit:
____New or lapsed permit over one year: $90.00
(good for three years (or part thereof the first year))
____Renewal of a current permit: $60.00
(good for three years (or part thereof the first year))
Previous VDWR Permit No:_________
____Mr. ____Mrs. ____Ms. ____Miss.
Applicant's Full Name: __________________________________
_____________________________________________________________________
Address:
City:
State:
Zip:
Email Address:_____________________________ County: _____________________
Date of Birth: __________________Last 4 of SSN:
Last 4 of Driver’s Lic#:
Phone Number: ______________________
Phone Number Where Employed: ___________________
Occupation: ____________________
Address where raptor (s) will be sheltered, if different from above:
___________________________
How many years have you practiced falconry? ___________________
Class of Permit: Apprentice ____ General ____ Master ____ (Check One)
If Apprentice Class, list name, address, falconry class, and federal permit # of sponsor:
_______________________________________________________________________
9/29/2020
VIRGINIA DEPARTMENT OF WILDLIFE RESOURCES
AND U. S. FISH AND WILDLIFE SERVICE
FALCONRY PERMIT APPLICATION (11 – FALC)
Under State Authority of §29.1-412, §29.1-419, Code of Virginia, 4 VAC 15-250
Under Federal Authority of 16 U.S.C. 701-712 and 50 C.F.R. §§13, 21.28, 21.29
State Fee (Non-Refundable) and Type of Permit:
____New or lapsed permit over one year: $90.00
(good for three years (or part thereof the first year))
____Renewal of a current permit: $60.00
(good for three years (or part thereof the first year))
Previous VDWR Permit No:_________
____Mr. ____Mrs. ____Ms. ____Miss.
Applicant's Full Name: __________________________________
_____________________________________________________________________
Address:
City:
State:
Zip:
Email Address:_____________________________ County: _____________________
Date of Birth: __________________Last 4 of SSN:
Last 4 of Driver’s Lic#:
Phone Number: ______________________
Phone Number Where Employed: ___________________
Occupation: ____________________
Address where raptor (s) will be sheltered, if different from above:
___________________________
How many years have you practiced falconry? ___________________
Class of Permit: Apprentice ____ General ____ Master ____ (Check One)
If Apprentice Class, list name, address, falconry class, and federal permit # of sponsor:
_______________________________________________________________________
9/29/2020
If General or Master Class, please list name, address, and federal permit # of all
apprentices:
1._____________________________________________________________________
2._____________________________________________________________________
3._____________________________________________________________________
Please provide the following information for each of the falconry raptors in your
possession at the present time:
Species
Band Number
Band Type and Color
1. _____________________ - ________________________ - ___________________
2. _____________________ - ________________________ - ___________________
3. _____________________ - ________________________ - ___________________
Age
Sex
Date of Acquisition
Source of
Birds
1. ______________ - ______________ - __________________ - ________________
2. ______________ - ______________ - __________________ - ________________
3. ______________ - ______________ - __________________ - ________________
CERTIFICATION
I certify that I have read and am familiar with the state regulations, and Title 50, Part 13,
of the Code of Federal Regulations and the other applicable parts in Subchapter B of
Chapter I of Title 50, and that the information I have submitted is complete and accurate
to the best of my knowledge and belief. I understand that any false statement herein may
subject me to the criminal penalties of 18 U.S.C. 1001.
Applicant's Signature: ___________________________ Date: _____________________
By my signature above, I hereby certify that all entries made on this application are true
and complete, and I agree and understand that any falsification of information herein,
regardless of time of discovery, may result in denial or revocation of my permit.
TYPED SIGNATURE IS AUTHORIZED AND BINDING PER CODE OF VIRGINIA
§59.1 CHAPTER 42.1 ET SEQ.
9/29/2020
*If under eighteen years of age, a signature of your parent/guardian is also required.
Parent/guardian Signature: ______________________ Date: _____________________
By my signature above, I hereby certify that all entries made on this application are true
and complete, and I agree and understand that any falsification of information herein,
regardless of time of discovery, may result in denial or revocation of my permit.
TYPED SIGNATURE IS AUTHORIZED AND BINDING PER CODE OF VIRGINIA
§59.1 CHAPTER 42.1 ET SEQ.
Make Check or Money Order payable to “Treasurer of Virginia” and mail to: Virginia
Department of Wildlife Resources, Permits Section, P. O. Box 3337, Henrico, VA 23228
FEDERAL NOTICE
In accordance with the Privacy Act of 1974 (PL 93-579), please be advised that:
1.
The gathering of information on fish and wildlife is authorized by :
(a) Bald Eagle Protection Act (16 U.S.C. 663a)
(b) Endangered Species Act of 1973 (16 U.S.C. 1539)
(c) Migratory Bird Treaty Act (16 U.S.C. 703-711)
(d) Lacey Act (18 U.S.C. 42 and 44)
(e) Tariff Classification Act of 1962 (19 U.S.C. 1202) and
(f) Title 50, Part 13, of the Code of Federal Regulations
2.
The disclosure of the requested information is required in order to process federal
applications for licenses or permits authorized under the above acts. With the
exception of your social security number, failure to disclose all of the information
may be sufficient cause for the U.S. Fish and Wildlife Service to deny you a permit.
3.
In the event there is indicated a violation of a statute, regulation, rule, order, or
license, whether civil, criminal, or regulatory in nature, the requested information
may be transferred to the appropriate Federal, State, local, or foreign agency
charged with investigating or prosecuting such violations.
4.
In the event of litigation involving the records or the subject matter of the records,
the requested information may be transferred to the U.S. Department of Justice.
9/29/2020
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