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FOR DEPARTMENT USE ONLY Arizona Game and Fish Department Date Received Region Date Reviewer Received Review Completion Date Approved Denied PLEASE PRINT OR TYPE Valid From To Social Security Number is voluntary-to be used for Sportsman s Database Only APPLICATION FOR WILDLIFE SERVICE LICENSE FEE NONE Name Date of Birth Address City Department ID Number/SSN Gender Phone Height State Zip Email Eyes Hair Business Name Telephone Numbers Day Night Days of the week you will be available for service General geographic area of service List below all species or groups of species of wildlife for which authorization is requested List methods of take removal Form 2721-A Revised 8/06 Attachments Additional information required under R12-4-421 Written narrative explaining applicant s experience in the capture handling and removal of wildlife specifying all species for which you have performed such function referencing the general location and dates that such services were performed methods used to carry out the activities and methods of disposition for the wildlife captured. Documentation that proves a minimum of six months full time employment or volunteer experience handling the wildlife listed above. APPLICANT SIGNATURE I certify the above is true and correct and that my live wildlife privileges are Date not revoked in this or any other state or the United States. APPLICANT SIGNATURE I certify the above is true and correct and that my live wildlife privileges are Date not revoked in this or any other state or the United States..

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