Hunter Education Customer Information Form printable pdf download

Hunter Education Customer Information Form

MARK WILLIAMS

DAN FORSTER

COMMISSIONER

DIRECTOR

HUNTER EDUCATION CUSTOMER INFORMATION FORM

You must go to and locate or create your GA-DNR Customer

Number to provide the information needed on this form.

Hunter Education Student Information:

GA-DNR Customer Number: ___________________________________________________

First Name: _____________________

Middle Name: ___________________

Last Name: _____________________

Date of Birth: _____/_____/________

Phone: ______________________________

Email: _______________________________

Important: You must attach your online or CD hunter education course completion certificate

to this form.

Warning: O.C.G.A 16-10-20; “A person who knowingly and willfully makes a false, fictitious or fraudulent

statement…in any manner within the jurisdiction of any department or agency of state government…shall,

upon conviction thereof, be punished by a fine of not more than$1000 or by imprisonment for not less

than five years, or both.” I understand that the purpose for completing this document is that the record

indicating a successful completion of the hunter education course cannot be found for the student

requested. I have completed this document as accurately as possible and hereby certify that I have read

and understand Georgia Law 16-10-20.

_______________________________________________________

Signature

Date

Return to:

Wildlife Resources Division

Hunter Education Coordinator

2065 US Hwy 278, SE

Social Circle, GA 30025 -or-

hd.temp2@dnr.ga.gov

GAME MANAGEMENT SECTION

2065 HWY 278 SE | SOCIAL CIRLCE, GEORGIA 30025

770.761.3010 | FAX 706.557.3042 |

Hunter Education Customer Information Form