NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION

DIVISION OF FISH, WILDLIFE & MARINE RESOURCES

ANNUAL FALCONRY REPORT FOR CALENDAR YEAR ENDING December 31, 2011

PLEASE PRINT OR TYPE:

Prefix: (Ms, Mrs, Mr): / Last Name: / First Name:
Street Address:
Mailing Address (if different from above):
City: / State: / Zip Code: / County:
Phone Number: / E-Mail Address: / State Falconry License #:

LOCATION OF MEWS: If different from address above.

Prefix: (Ms, Mrs, Mr): / Landowner Last Name: / Landowner First Name:
Street Address:
Mailing Address (if different from above):
City: / State: / Zip Code: / County:
Phone Number: / E-Mail Address: / State Falconry License #:

1. RAPTORS IN YOUR POSSESSION AT THE BEGINNING OF CALENDAR YEAR:

Band Number / Species / Sex / Date Originally Obtained / Origin* / Where Obtained**
*Origin: (E=Eyas, P=Passage, CB=Captive Bred, O=Other) **Where Obtained: (Enter State/County or, Individual’s Name)

2. RAPTORS ACQUIRED DURING THE CALENDAR YEAR:

Band Number / Species / Sex / Date Obtained / Origin* / Where Obtained**
*Origin: (E=Eyas, P=Passage, CB=Captive Bred, O=Other) **Where Obtained: (Enter State/County or, Individual’s Name)

3. RAPTORS ESCAPED OR LOST DURING THE CALENDAR YEAR:

Band Number / Species / Date Originally Obtained / Physical Condition / Equipment Lost / Location / Escape Date

4. RAPTORS THAT DIED DURING THE CALENDAR YEAR:

Band Number / Species / Date Originally Obtained / Cause of Death / Date of Death

5. RAPTORS TRANSFERRED TO ANOTHER PERSON DURING THE CALENDAR YEAR:

Band Number / Species / Date Originally Obtained / Transferred to (Name, address, phone number, e-mail address) / Their State and Federal License Numbers / Date Transferred

6. RAPTORS INTENTIONALLY RELEASED TO THE WILD DURING THE CALENDAR YEAR:

Band Number / Species / Date Originally Obtained / Physical Condition / Location Released / Date Released

7. BANDS REPLACED DURING THE CALENDAR YEAR:

Old Band Number / Species / Date Originally Obtained / New Band Number / Why the Band was Replaced? / Date Band Replaced

8. HUNTING ACTIVITIES DURING THE CALENDAR YEAR

Total Number of Species taken during the Calendar Year
Raptor Species Possessed / Days Hunted / Rabbit / Squirrel / Pheasant / Duck / Grouse / Quail / Non-Game / Did not Hunt

9. SIGNATURE

NOTICE: Pursuant to ECL Section 3-0301(2)(a), false statements made on this document are punishable pursuant to Section 210.45 of the New York Penal Law.
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SIGNATURE DATE