1.        Make check or money order payable to WV Division of Natural Resources. This fee is
           non-refundable.
2.        Print or type all information
3.        Return completed application to: WVDNR, Law Enforcement-Falconry, Capitol
           Complex Building 3, Room 837, Charleston, WV 25305.

_____ NEW ($250.00)____ RENEWAL ($100.00) ____LAPSED RENEWAL ($250.00)

NAME__________________________________________________________________
	               (First)	       (Middle)	         (Last)

STREET__________________________________________ CITY __________________

COUNTY____________________________ STATE____________ZIP___________

PHONE NUMBER (HOME)________________________(WORK)___________________

SOCIAL SECURITY NUMBER________________DATE OF BIRTH________AGE______

DO YOU CURRENTLY HOLD ANY OTHER STATE OR FEDERAL LICENSES OR PERMITS?
 ______YES ______NO

If yes, list license or permit numbers (attach copy(s)]_____________________________________

How many years have you practiced falconry?_________________________________________

CLASS APPLIED FOR________APPRENTICE________GENERAL__________MASTER


If APPRENTICE CLASS, list name, address, falconry class, and state permit number of sponsor(and have sponsor
 certify below):

____________________________________________________________________________________________

If GENERAL or MASTER CLASS, please list name, address and state permit number of all apprentices:

1.__________________________________________________________________________________________

2.__________________________________________________________________________________________

3.__________________________________________________________________________________________