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Possession Permit Application For Am Exotic Wild Animal Form - Department Of Environmental Management

EPARTMENT OF

NVIRONMENTAL

ANAGEMENT

& R

IVISION OF

GRICULTURE

ESOURCE

ARKETING

235 Promenade Street, Room 370, Providence, RI 02908-5767

Phone: 401-222-2781 Fax: 222-6047 TDD: 711

POSSESSION PERMIT APPLICATION FOR AN EXOTIC WILD ANIMAL

PERMIT FEE $5.00 PER SPECIMEN / ONE APPLICATION PER SPECIMEN

This application must be filled out COMPLETELY or application may not be processed.

OWNER / IMPORTER INFORMATION

Name: _____________________________________________________________________________

Address: ___________________________________________________________________________

City: ________________________________________State: _________ Zip code: _______________

Phone: (_____)______________________ Phone (Alternate/Cell): (_____)______________________

EXOTIC SPECIMEN INFORMATION

Species (Common name): _____________________________________________________________

_______________________________________________________________

True Scientific Name:

Individual Identification: ________________________________ Gender: ________ Age: _________

Carrier and probable of point of first arrival: _____________________________________________

The location where the animal will be held in QUARANTINE pending tests/veterinary examination

including PHONE number: ___________________________________________________________

___________________________________________________________________________________

Location where animal will be permanently housed following quarantine: ____________________

___________________________________________________________________________________

□ Breeding

□ Zoo □ Pet Ownership

The purpose for which animal will be imported:

□ Exhibition □ Other (Specify): _____________________________________________________

The full consignee name: ______________________________________________________________

The full consignee address: ____________________________________________________________

The full consignor name: ______________________________________________________________

The full consignor address: ____________________________________________________________

VETERINARIAN:

Name: _____________________________________Hospital name: ____________________________

Hospital Address: _____________________________________________________________________

Telephone: __________________________________ FAX: __________________________________

Possession Permit Application For Am Exotic Wild Animal Form - Department Of Environmental Management