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 .