For Office Use Only LICENSE DURATION 1 Year or 5Years Black Bear License # ______Fee Paid $ ______LICENSE FEE Tracking Dog License ☐ ☐ $25.00 1 Year Check # ______Application ☐ 00 $100. 5 Year ☐ M.O. # ______For more information on this license visit www.dec.ny.gov/permits/25006.html

*APPLICANT INFORMATION name / date of birth ______Last First M.I. DOB (mm/dd/yyyy) address ______Street Address Apartment/Unit City ______County State Zip Code email / ______( ______) ______- ______telephone Email Telephone

*Provide your NYS Hunting License ID # (must be current year license)

*FACILITY / BUSINESS INFORMATION (Complete this section if different from above.) facility / business name ______address ______Street Address Apartment/Unit City

______( ______) ______- ______County State Zip Code Telephone

REQUIRED DOCUMENT(S) APPLICATION CHECKLIST (must be submitted with your application) (before sending this application, please verify the following) Check or money order for the appropriate 1 year or 5 year license fee made ☐ ☐ All application fields/sections marked with an asterisk ( * ) are complete1 payable to: “NYS Department of Environmental Conservation” ☐ You signed and dated below

By signing below, I:

• Understand and agree that all dogs used under authority of this license must be licensed, vaccinated and identified in accordance to the NYS Agriculture and Markets Law (Article 7). • Understand and agree only the following breeds or crossbreeds may be used to track black bear under authority of this license: Airedale, American Black and Tan Coonhound, Bluetick Coonhound, Majestic Tree Hound, Mountain Cur, Leopard Cur, English Coonhound, Plott Hound, Redbone Coonhound, Treeing Walker, Black Mouth Yellow Cur, and Karelian Bear Dog. • Certify that I have not been convicted of, pled guilty to, or settled by civil settlement or otherwise, for the illegal taking of a black bear or the illegal sale of black bear parts within the last five years.

*NOTICE: Pursuant to ECL Section 3-0301(2)(Q), false statements made on this application are punishable in accordance to Section 210.45 of the New York State Penal Law. ______Applicant’s Signature Date

MAIL YOUR COMPLETED APPLICATION AND REQUIRED DOCUMENT(S) TO: For questions or concerns, please contact us NYS Department of Environmental Conservation Phone: (518) 402-8985 ∙ Fax: (518) 402-8925 Special Licenses Unit ∙ 5th Floor Email: [email protected] 625 Broadway, Albany, New York 12233 Website: www.dec.ny.gov/63.html

Please allow 45 days for DEC to review and process your application. 1Incomplete or vague applications will be returned and delay the processing of your permit.

Revised 8/2016  NYSDEC  DFW  Special Licenses Unit  Black Bear Tracking Dog License Application  Page 1 of 1