Utah Division of Wildlife Resources Application for Reptile Collection Certificate of Registration Applications must be received through mail, email, or in person at the DWR Salt Lake Office Only by January 19, 2018 5:00 pm. Utah Division of Wildlife Resources, ATTN: Wildlife Registration Office, PO Box 146301; 1594 W North Temple, Ste. 2110; Salt Lake City, UT 84114-6301 or email [email protected]. There is a $10.00 non-refundable handling fee and must be included when submitting application. You may enclose a check or money order payable to DWR, pay in person at a Division Office or arrange to make a credit card payment over the phone. Please list your phone number here to arrange payment by phone. The $75.00 Certificate of Registration fee will be collected from successful applicants upon approval. If necessary, a drawing will be conducted for those species that have more applications than available permits on January 24. Remaining permits will be available January 25 on a first-come, first-served basis at the DWR Salt Lake Office. Name________________________________ Phone_______________________ Email________________________ Address____________________________ City___________________ State________ ZIP________________ Date of Birth___________________________ Limit Total Collection Species per Authorized County Permits Season County California Kingsnake 6 2 Garfield, Kane, and San Juan March 1 - Oct 31 Daggett, Duchesne, Salt Lake, Summit, Smooth Greensnake 6 1 March 1 - Oct 31 Utah, Uintah, Wasatch, and Weber Beaver, Daggett, Garfield, Iron, Kane, Utah Milksnake 6 1 Millard, Piute, Salt Lake, Summit, Tooele, March 1 - Oct 31 Uintah, Wasatch, and Washington Beaver, Garfield, Iron, Juab, Kane, Piute, Utah Mountain Kingsnake 6 1 March 1 - Oct 31 Sevier, Utah, and Washington Select one species below and the counties of choice for collection California Kingsnake (Lampropeltis getulacaliforniae) Smooth Greensnake (Opheodrys vernalis) 1st County Choice 1st County Choice 2nd County Choice 2nd County Choice 3rd County Choice 3rd County Choice Utah Milksnake (Lampropeltis triangulum taylori) Utah Mountain Kingsnake (Lampropeltis pyromelana infralabialis) 1st County Choice 1st County Choice 2nd County Choice 2nd County Choice 3rd County Choice 3rd County Choice APPLICATION MUST BE SIGNED: All statements on this form are true and correct. I understand that if I subscribe to any false statement on this application, I am subject to criminal prosecution. I certify that I am eligible for the permit for which I have applied. I declare under penalty of perjury that I am qualified under all prevailing laws and statutes to purchase or possess this permit. X Date Applicant Signature.