Report created by RaptorMed (www.raptormed.com)

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.)

Educational [  ] Scientific [  ] Zoological [  ] Rehabilitation [ X ]
Permit number:TO BE FILLED INPermit period: <>
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.)

Educational [  ] Scientific [  ] Zoological [  ]
Permit number:<>Permit period: <>
Permittee Information: <>
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.)

Common nameScientific nameQuantityLiveN/RDead
<><>1010
 

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.

Signature of Donor:

_______________________________
  Date:

  _______________________________
 

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..

Signature of Recipient:

_______________________________
  Date:

  _______________________________
PWD 1143 - W7000 (11/06)