<p>Utah Division of </p><p>Wildlife Resources </p><p>Application for Reptile Collection Certificate of Registration </p><p>Applications must be received through mail, email, or in person at the DWR Salt Lake Office Only <strong>by January 19, 2018 5:00 pm</strong>. Utah&nbsp;Division of Wildlife Resources, ATTN: Wildlife Registration Office, PO Box 146301; 1594 W North Temple, Ste. 2110; Salt Lake City, UT 84114-<a href="mailto:[email protected]" target="_blank">6301 or email </a><a href="mailto:[email protected]" target="_blank">[email protected]. </a></p><p>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 </p><ul style="display: flex;"><li style="flex:1">the phone. Please list your phone number here </li><li style="flex:1">to arrange payment by phone. The </li></ul><p>$75.00 Certificate of Registration fee will be collected from successful applicants upon approval. </p><p>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. </p><p>Name________________________________ Phone_______________________&nbsp;Email________________________ </p><p>State________ </p><ul style="display: flex;"><li style="flex:1">ZIP________________ </li><li style="flex:1">Address____________________________ City___________________ </li></ul><p>Date of Birth___________________________ </p><p><strong>Limit </strong></p><ul style="display: flex;"><li style="flex:1"><strong>Total </strong></li><li style="flex:1"><strong>Collection </strong></li></ul><p><strong>Season </strong></p><ul style="display: flex;"><li style="flex:1"><strong>Species </strong></li><li style="flex:1"><strong>per </strong></li><li style="flex:1"><strong>Authorized County </strong></li></ul><p><strong>Permits </strong><br><strong>County </strong></p><p>California Kingsnake Smooth Greensnake <br>66<br>21</p><ul style="display: flex;"><li style="flex:1">Garfield, Kane, and San Juan </li><li style="flex:1">March 1 - Oct 31 </li></ul><p>March 1 - Oct 31 <br>Daggett, Duchesne, Salt Lake, Summit, Utah, Uintah, Wasatch, and Weber Beaver, Daggett, Garfield, Iron, Kane, Millard, Piute, Salt Lake, Summit, Tooele, Uintah, Wasatch, and Washington </p><ul style="display: flex;"><li style="flex:1">Utah Milksnake </li><li style="flex:1">6</li></ul><p>6<br>11<br>March 1 - Oct 31 March 1 - Oct 31 <br>Beaver, Garfield, Iron, Juab, Kane, Piute, Sevier, Utah, and Washington <br>Utah Mountain Kingsnake <br>Select one species below and the counties of choice for collection </p><p>Smooth Greensnake <em>(Opheodrys vernalis) </em></p><p>1st County Choice </p><p>California Kingsnake <em>(Lampropeltis getulacaliforniae) </em></p><p>1st County Choice <br>2nd County Choice <br>2nd County Choice </p><p>3rd County Choice <br>3rd County Choice </p><p>Utah Mountain Kingsnake <em>(Lampropeltis pyromelana infralabialis) </em><br>Utah Milksnake <em>(Lampropeltis triangulum taylori) </em></p><p>1st County Choice <br>1st County Choice 2nd County Choice 3rd County Choice <br>2nd County Choice 3rd County Choice </p><p><strong>APPLICATION MUST BE SIGNED: </strong>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. </p><p><strong>X</strong></p><p>Date </p><p>Applicant Signature </p>