Revised 2015

Kentucky Department of Fish & Wildlife Resources

SPECIAL COMMISSION PERMITS

Application Form

Organizations must provide this information even if an application was completed in previous years.

Application must be postmarked by MAY 1. Permit to be awarded at the June Commission Mtg.

ORGANIZATION INFORMATION

Organization: Click here to enter text.

Address: Click here to enter text.

Contact Person: Click here to enter text. Telephone #: Click here to enter text.

Email Address: Click here to enter text.

PERMITS

Please mark (X) the permit(s) requested:

SPRING TURKEY: Click here to enter text. FALL/WINTER DEER: Click here to enter text. FALL ELK: Click here to enter text. FALL/WINTER WATERFOWL: Click here to enter text.

Method of transferring permits to individual (Auction, Raffle, etc.): Click here to enter text.

PROCEEDS

Estimated dollar amount to be raised: Click here to enter text.

Rationale for this estimate: Click here to enter text.

PROJECT

Proposed wildlife conservation project(s) for which proceeds will be used: Click here to enter text.

PAST COMMISSION PERMIT AWARDS

If you applied and were awarded a special permit in the past, please list the year & type of permit, net proceeds for each permit, and a summary of the conservation project(s) funded: Click here to enter text.

FUND-RAISING HISTORY

List past examples of fundraising, including the money raised, and any other methods used that demonstrate fundraising ability: Click here to enter text.

EXPERIENCE WITH CONSERVATION PROJECTS

List past experience with natural resource conservation projects that have enhanced fish and wildlife, habitats, fish and wildlife education, or fish and wildlife-related recreation. Please include years of such experience: Click here to enter text.

THE PROPOSED PROJECT’S POTENTIAL FOR ENHANCING FISH AND WILDLIFE, HABITATS, FISH AND WILDLIFE EDUCATION, OR FISH AND WILDLIFE-RELATED RECREATION IN KENTUCKY

Please explain how your proposed conservation project will support one or more of the above categories: Click here to enter text.

PER THE REQUIREMENTS OF 301 KAR 3:100, PLEASE ATTACH:

One copy of your organization’s Articles of Incorporation or Bylaws.

Written proof of your organization’s federal tax-exempt status including the individual tax ID number.

If applicable, a letter from your organization’s parent organization that states your chapter is in good-standing and is recognized by the parent organization.

Failure to disclose and attach the requested information will result in a disqualification from consideration.

SIGNATURE

I attest that the provided information is truthful and accurate and agree to comply with the requirements of KRS Chapter 150 and 301 KAR 3:100.

_________________________________________________	________________________

Authorized Officer of Conservation Organization	DATE

SEND COMPLETED APPLICATION AND ACCOMPANYING DOCUMENTS TO:

Kentucky Department of Fish and Wildlife Resources

#1 Sportsman’s Lane

Frankfort, KY 40601

ATTENTION: Commission Permit Application

ALL MAIL MUST BE POSTMARKED BY MAY 1