TEXAS Parks & Wildlife |
Receipt for Donation of Fish or Wildlife Specimens | ||||||||||||||
Source (Please place and "X" in one box and provide a valid permit number and the permit period of validity.) |
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Educational [ ] Scientific [ ] Zoological [ ] Rehabilitation [ X ] | |||||||||||||||
Permit number: | TO BE FILLED IN | Permit period: < |
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Permittee Information: |
Erich Neupert Blackland Prairie Raptor Center 1625 Brockdale Park Road Lucas, TX 75002 469-964-9696 Erich.neupert@bpraptorcenter.org |
AZA Accredited? Yes [ ] NO [ X ] | |||||||||||||
Destination (Please place and "X" in one box and provide a valid permit number and the permit period of validity.) |
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Educational [ ] Scientific [ ] Zoological [ ] | |||||||||||||||
Permit number: | < | Permit period: < |
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Permittee Information: |
< |
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AZA Accredited? Yes [ ] NO [ ] | |||||||||||||||
Specimens: (Live refers to live healthy specimens; NR refers to live specimens deemed as non-releasable; Dead refers to non-living specimens to be used for research, as voucher specimens or preserved/mounted specimens for display.) |
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Source Signature: I certify that I, (place an "X" in one) [ ] permittee or [ ] sub-permittee, am authorized by my permit to donate the above referenced specimens to other Scientific, Educational and/or Zoological permit holders who are authorized to receive such specimens. |
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Signature of Donor: _______________________________ |
Date: _______________________________ |
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Destination Signature: I certify that I, (place an "X" in one) [ ] permittee or [ ] sub-permittee, am authorized by my permit to receive the above referenced specimens.. |
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Signature of Recipient: _______________________________ |
Date: _______________________________ |
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PWD 1143 - W7000 (11/06) |