SECTION 1. PERSONAL INFORMATION

First Name:    Please enter your first name   
Last Name: Please enter your last name   
Birthdate:       Please enter your birthdate Invalid birthdate format. Must be MM/DD/YYYY
Organization:
Mailing Address: Please enter your mailing address   
City: Please enter your city   
State: Please enter your state   
ZipCode: Please enter your zipcode
Daytime Phone Number: Invalid phone number   
E-Mail: Please enter your e-mail address  Invalid e-mail address SECTION 2. PERMIT INFORMATION

Most recent IDNR Scientific Collector Permit Number if applicable:
U.S. Fish and Wildlife Service Permits:

Master Permittee:
Permit Number:
Type of Permit Requested:
Collect Live Individuals Salvage Dead Specimens or Parts Both Collect Live and Salvage Please select a permit type
Other individuals to be covered by this permit:
Permit holders granted authorization under 520 ILCS 5/3.22 and 515 ILCS 5/20-100 of the Illinois Compiled Statutes and 17 ILL. Adm. Code 520 may handle species not listed as endangered or threatened in Illinois. If you select “yes” to the following question, then an additional permit is needed.
   

Will the project involve species listed as state endangered or threatened? (Yes/No)   Yes No
SECTION 3. APPLICANT QUALIFICATIONS

Highest Degree Earned: Please enter your highest degree earned
Degree Institution:   Please enter your degree institution name     
Degree Year: Please enter your degree year   Please enter a 4 digit year     
 Major:

Current Work Position Information:  

Work Position:
Job Title:
Work Institution:
Employment Dates:
Species Handled:

Other qualifications that relate to the permit request:
SECTION 4: DESCRIPTION OF PROJECT

Title of Project: Please enter your project title
Duration of Project: Please enter your project duration
Is your project directed or funded by IDNR? (Yes/No)   Yes No
If yes, what is the IDNR Contract or Grant Number or Project Name:
Description of the project including common names of species targeted and why the project is proposed:
Please enter your project description
Describe the methods to be used:
Please enter your project methods
Disposition of Collected or Salvaged Specimens:
Please enter your project specimen disposal information
Location of Project (Please list the counties and/or watersheds where your project occurs):
Please enter your project location information

Will the project occur on Illinois Nature Preserve Commission sites? (Yes/No)    Yes No Unsure
Will the project occur on IDNR property? (Yes/No)   Yes No Please choose if the project will occur on IDNR Property.