Form 2723-B "Wildlife Rehabilitation Agent License Application" - Arizona

What Is Form 2723-B?

This is a legal form that was released by the Arizona Game and Fish Department - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2017;
  • The latest edition provided by the Arizona Game and Fish Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 2723-B by clicking the link below or browse more documents and templates provided by the Arizona Game and Fish Department.

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Download Form 2723-B "Wildlife Rehabilitation Agent License Application" - Arizona

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A
G
F
D
RIZONA
AME AND
ISH
EPARTMENT
WILDLIFE REHABILITATION AGENT LICENSE APPLICATION
R12-4-423
Date Received
Region:
Date Review Complete
FOR DEPARTMENT USE
Approved:
Denied:
ONLY
Valid
From:
To:
Approved By:
Date:
FEE: None
[PLEASE PRINT OR TYPE]
Calendar Year
NEW
or
RENEWAL
Department ID Number or SSN:
Date of Birth
Name
Mailing Address
City
Phone
State
Zip
Eyes
Gender
Weight
Height
Hair
Resident
Number of Years Resident
Non Resident
Facility Address
)
(if different than mailing
or UTM
Lat/Long
(decimal degrees only)
Email
(if applicable)
Organization Name
Website
For each location where wildlife will be held:
(if other than your residence)
Species held at this location
Land Owners Name
Phone
Mailing Address
City
State
Zip
Lat/Long
or UTM
(decimal degrees only)
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.
Amphibians
Mammals
Reptiles
Nongame mammals
Check All
Birds
Bats
that Apply
Quail (order Galliformes)
Big Game (except cervids)
Dove (order Columbiformes)
Carnivores
Hummingbirds (order Trochiliformes)
Small Game
Passerine birds (order Passeriformes)
Other
Raptors (orders Falconiformes or Strigiformes)
Non-Passerine birds (birds not listed above)
A Federal Rehabilitation
License is also required to
work with Migratory birds
Rehabilitator's
and T&E species
USFWS Permit #
Exp Date
FORM 2723-B Revised 1/17 FOLE
A
G
F
D
RIZONA
AME AND
ISH
EPARTMENT
WILDLIFE REHABILITATION AGENT LICENSE APPLICATION
R12-4-423
Date Received
Region:
Date Review Complete
FOR DEPARTMENT USE
Approved:
Denied:
ONLY
Valid
From:
To:
Approved By:
Date:
FEE: None
[PLEASE PRINT OR TYPE]
Calendar Year
NEW
or
RENEWAL
Department ID Number or SSN:
Date of Birth
Name
Mailing Address
City
Phone
State
Zip
Eyes
Gender
Weight
Height
Hair
Resident
Number of Years Resident
Non Resident
Facility Address
)
(if different than mailing
or UTM
Lat/Long
(decimal degrees only)
Email
(if applicable)
Organization Name
Website
For each location where wildlife will be held:
(if other than your residence)
Species held at this location
Land Owners Name
Phone
Mailing Address
City
State
Zip
Lat/Long
or UTM
(decimal degrees only)
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.
Amphibians
Mammals
Reptiles
Nongame mammals
Check All
Birds
Bats
that Apply
Quail (order Galliformes)
Big Game (except cervids)
Dove (order Columbiformes)
Carnivores
Hummingbirds (order Trochiliformes)
Small Game
Passerine birds (order Passeriformes)
Other
Raptors (orders Falconiformes or Strigiformes)
Non-Passerine birds (birds not listed above)
A Federal Rehabilitation
License is also required to
work with Migratory birds
Rehabilitator's
and T&E species
USFWS Permit #
Exp Date
FORM 2723-B Revised 1/17 FOLE
I am a licensed veterinarian
License #
State
I affirm
I have a licensed veterinarian available to provide services when necessary
Name of Veterinarian
Phone
Clinic Address
State
Zip
City
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 of experience handling the wildlife listed above. Include your experience
training and experience
handling, capturing, rehabilitating and caring for wildlife listed under section L(4).
Provide your preferred method of disposition of non-releasable wildlife.
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 facilities comply with captivity standards of R12-4-428. Include any additions or changes to
facilities when submitting a renewal applications
License #
Sponsoring Rehabilitator's Name
Rehabilitator's Signature:
Date
st
***RENEWAL APPLICATIONS MUST BE RECEIVED OR POSTMARKED BY DECEMBER 31
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.
Date
Applicant Signature:
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.
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.
Department Use Only
Completed 8 hrs Cont Ed
Annual report(s) received
Facility inspection completed
Sponsoring Rehabber has Federal permit for Migratory birds
FORM 2723-B Revised 1/17 FOLE
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