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.

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

Download PDF

Fill PDF online

Rate (4.3 / 5) 8 votes

Show Pagination

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

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)

(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

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

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)

(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

***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