Application For Aviary License Form - Department Of Environmental Management

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DEM Use Only:
D
E
M
EPARTMENT OF
NVIRONMENTAL
ANAGEMENT
Number: __________/__________
Approved By: ________________
D
A
& R
M
IVISION OF
GRICULTURE
ESOURCE
ARKETING
Date: ________________________
235 Promenade Street, Room 370, Providence, RI 02908-5767
Phone: 401-222-2781 Fax: 222-6047 TDD: 711
APPLICATION FOR AVIARY LICENSE
In accordance with Title 4, Chapter 11, of the General Laws, 1956 as amended, entitled Psittacine Birds, the
undersigned hereby registers and agrees to conform to all the provisions of said Chapter, and all regulations
st
issued under the authority thereof. Registration must be renewed annually by January 1
.
Name of Facility: ____________________________________________________________________
Owner’s Name: _______________________________Contact Name: __________________________
Street Address: ______________________________________________________________________
Town or City: _________________________________State: ___________ Zip Code: ____________
Mail Address (if different from above): __________________________________________________
Town or City: _________________________________State: ___________ Zip Code: ____________
Telephone: ___________________________________FAX: _________________________________
Email: _______________________________________Website: ______________________________
OWNER INFORMATION:
Name of Owner: _____________________________________________________________________
Home Address: ______________________________________________________________________
Town or City: ____________________________________State: __________ Zip Code: ___________
Home Phone # ______________________________________________________________________
After Hours Telephone / Emergency Contact: _____________________________________________
MANAGER INFORMATION:
Name of Manager: ___________________________________________________________________
Manager’s Address: __________________________________________________________________
Town or City: _________________________________State: ___________ Zip Code: ____________
Manager’s Home Phone: ______________________________________________________________
BIRD INVENTORY
Breed(s) of Birds Raised: ___________________, ____________________, ____________________
__________________, __________________, ____________________, _______________________
Number of Birds on Hand: ________Closed Banded: __________ Not Closed Banded: ____________
Number Annually Raised: ________ SOLD: _________________ PURCHASED: ________________
No. Sold WHOLESALE: _________ WHERE: ____________________________________________
No. Sold RETAIL: ______________ WHERE: ____________________________________________
Breeder’s BAND CODE: ________________
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