Form Pwd 0153-W7000 - Landowner Request For Technical Guidance (Page 2 of 2) in pdf

Authorization of a Designated Agent

1. I hereby authorize the following person to serve as a designated agent on my behalf

for properties under my control designated below. Designated agent authorization

may be rescinded in writing by the landowner at any time.

2. I understand that by designating an agent I have given this person the authority to

act on my behalf to participate in, fulfill requirements of, and be responsible for

conducting habitat management practices required for Texas Parks & Wildlife

Department programs, permits, or assistance requests. In addition, I understand that

failure by the designated agent to fulfill permit or program requirements could

jeopardize my participation in those programs.

3. I understand the designated agent is responsible for keeping me informed of all

correspondence and documents provide by Wildlife Division staff, unless otherwise

directed by me.

Section 65.3 of the Parks and Wildlife Administrative Code defines an agent as “A person

authorized by the landowner to act on behalf of the landowner.” This implies the agent shall have

the same legal authority as the landowner to make decisions regarding participation in TPWD

programs, permits, or assistance requests, and meeting program or permit requirements.

Signed:________________________________________________________________

Landowner Signature ONLY

Date

Property Name:__________________________________ County:_________________

Designated Agent Name

:________________________________________

(Please Print)

Mailing Address:_________________________________________________________

City, State, Zip:__________________________________________________________

Home:__________________ Office:__________________ Cell:___________________

Email:_________________________________________________________________

Notes / Other Instructions for Designated Agent or TPWD:_

_________________________

_____________________________________________________________________________

Title V Compliance: The Texas Parks and Wildlife Department provides this service to land managers without discrimination in respect to race,

color, national origin, age or handicap.

Texas Parks and Wildlife Department maintains the information collected through this form. With few exceptions, you are entitled to be

informed about the information we collect. Under Sections 552.021 and 553.023 of the Texas Government Code, you are also entitled to

receive and review the information. Under Section 559.004, you are also entitled to have this information corrected. For assistance call 512-

389-8119.

PWD 0153-W7000 (09/2013)

Form Pwd 0153-W7000 - Landowner Request For Technical Guidance Page 2