SECTION 1. PERSONAL INFORMATION

First Name:        
Last Name:     
Birthdate:          
Organization:
Mailing Address:     
City:     
State:     
ZipCode:  
Daytime Phone Number:     
E-Mail:      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  
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:  
Degree Institution:         
Degree 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:  
Duration of Project:  
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:
 
Describe the methods to be used:
 
Disposition of Collected or Salvaged Specimens:
 
Location of Project (Please list the counties and/or watersheds where your project occurs):
 

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