Form 01-805 - Request For Duplicate License(S) printable pdf download

COMMERCIAL FISHERIES ENTRY COMMISSION

CFEC USE ONLY

EFF. DATE ____________________________

8800 Glacier Highway, #109, Juneau, Alaska 99801

DATE MAILED ________________________

(907) 789-6150 ph., (907) 789-6170 fax

DATE DENIED ________________________

Request for Duplicate License(s)

FEES PAID $ __________________________

INSTRUCTIONS: This form may be used to request a replacement permit card, vessel license or permit certiﬁ cate when the original has been lost, sto-

len or damaged. If the original license was not received in the mail, a duplicate license may be requested by submitting the form along with the fees due.

When a request for a duplicate permit card or vessel license is approved, the original license becomes VOID and it is then ILLEGAL for it to be used at

any time. The appropriate fees for the duplicate licenses requested must be submitted with the Request for Duplicate form. Checks, money orders or

credit cards can be used to pay the fees. Do Not Send Cash (If cash is mailed but not received at CFEC, the Duplicate is invalid until paid).

The second page of the completed form may be used as a temporary permit or vessel license ONLY if the bottom section of the form has been validated

by an employee of the Entry Commission, the Dept. of Fish and Game or the Alaska Bureau of Wildlife Enforcement. In this case, the top page should

be mailed to CFEC, the copy may be kept by the applicant for use as a temporary permit or vessel license. The permit number (including the D or Y at

the end) must be written by hand on the ﬁ sh tickets. If the original license(s) were not received in the mail, an agent may validate the form ONLY

after contacting CFEC for approval.

Check boxes to indicate the duplicate licenses needed:

Fees:

Original license was:

Permit Card No. _________________________________ D

$20

Lost

Stolen

Damaged

No. _________________________________ D

$20

Explain what happened to the original license, if known:

Emergency Transfer Permit Card

No. __________________________________ Y

$20

______________________________________________

Certiﬁ cate, Permit No. _____________________________

no fee

______________________________________________

Vessel ADF&G Number Plate, No. ____________________

$20

______________________________________________

(triangular metal number plate)

Never Received in the Mail

License Receipt Card, No. __________________________

$20 *

The carbon copy of this form may be used as a temporary

license ONLY if authorized by CFEC. The following sec-

Vessel License Annual Sticker, No. ___________________

$20 *

tion must be completed by the agent indicating the name

of the CFEC employee contacted:

Vessel License Salmon Area Reg. Tab (Area ___________ )

no fee

CFEC CONTACTED BY_____________________________________ ON:

* Only one $20 fee is required for a vessel sticker and/or receipt card.

APPROVED

CHECK THIS BOX IF VESSEL OWNERSHIP HAS CHANGED SINCE THE CURRENT

DENIED

LICENSE WAS ISSUED. INDICATE THE DATE OF THE OWNERSHIP CHANGE,

DATE

TIME

CFEC EMPLOYEE

______________________ , AND PROVIDE NEW OWNER INFORMATION BELOW.

DATE OF CHANGE

CERTIFICATION OF APPLICANT

I swear under penalty of perjury that all information supplied by me on this form and in all supporting documents is true and complete to the best of my

knowledge. I further certify that I am the:

permit holder

vessel owner

agent for the vessel owner

other (explain)

____________________________________________

___________________________________

________________

_____________

Name of Permit Holder or Vessel Owner (printed)

Social Security No.

Date of Birth

ADF&G No.

Permanent Mailing Address: _____________________________________________________________________________________________

Mailing Address for Duplicate(s) (if different): ________________________________________________________________________________

_____________________________________________________________________________________________________________________

____________________________________________________

Signature of Applicant

Subscribed and sworn to before me this ______ day of ______________ , 200 _______ , at __________________________________________

____________________________________________________

Notary Public or Alaskan Postmaster

CREDIT CARD PAYMENT INFORMATION

( ) CHECK/MONEY ORDER ENCLOSED ( ) MASTERCARD ( ) VISA

EXP DATE

Comm. Expires: _______________________________________

____________________________________________________

SIGNATURE OF CARD HOLDER IF NOT APPLICANT

DATE

THE CARBON COPY OF THIS FORM MAY BE USED AS A TEMPORARY LICENSE FOR UP TO 14 DAYS ONLY IF IT IS SIGNED BELOW BY AN AUTHORIZED AGENT OR EMPLOYEE OF THE

ENTRY COMMISSION, DEPT. OF FISH AND GAME OR DIVISION OF FISH AND WILDLIFE PROTECTION.

___________________________________________________

________________________________________

___________________________

__________________

_____________

SIGNATURE OF AGENT

NAME (PRINTED)

OFFICE & TITLE

DATE SIGNED

VALID UNTIL

01-805 (REV12/05)