Fill - Free fillable CLASS III PERSONAL USE APPLICATION AND QUESTIONNAIRE PDF form

FWCDLE 621 (08/08) PERMITTEE

PLEASE PRINT OR TYPE (NO PENCIL) ALL INCOMPLETE APPLICATIONS WILL BE RETURNED

I, dob , hereby request authorization to maintain the

Permittee

following wildlife for personal use,

Number(s) and Type(s)

to be maintained at, Location Address:

City State Zip Code

Same as location address

Mailing Address:

City State Zip Code

Home Telephone: ( ) Business Telephone: ( )

IMPORTANT: Terms and Conditions of Wildlife Pet Permits -- Permits are issued upon the provision that said wildlife be kept in a

safe, sanitary and humane manner. All wildlife pets shall be kept under strict supervision by the permittee or safely caged at all times.

Extreme caution shall be exercised to protect persons from being injured by wildlife. Failure to adequately protect the public from injury

is a violation of permit guidelines. Because of the danger of rabies, especially in raccoons and skunks, incidents involving injury to

persons shall be immediately reported to the county health department and the animal is subject to seizure by Florida Fish and Wildlife

Conservation Commission (FWC) officers and submitted for rabies testing. Consideration must be given to the disposition of the above

animal(s) should I no longer want it or am unable to provide proper care. I understand that 379.231, F.S. and 68-5.001 Florida

Administrative Code, prohibits the release of any non-native animal. Furthermore, that 68A-6.0021, F.A.C., prohibits the acquisition or

sale or transfer of wildlife to or from anyone not authorized to posses such wildlife.

I hereby agree to abide by all regulations of the FWC regarding the keeping of wildlife pets.

Signature Date

DO NOT WRITE BELOW LINE, FOR FWC USE ONLY.

NOT VALID WITHOUT FWC SEAL

FLORIDA FISH AND WILDLIFE CONSERVATION COMMISSION SEAL

Approved By:

Permit Expires:

Denied By:

Reasons:

RETURN COMPLETED APPLICATION AND QUESTIONNAIRE TO:

FWC, Division of Law Enforcement

Investigation Section

620 South Meridian Street

Tallahassee, Florida 32399-1600

NOTE: ALL INCOMPLETE APPLICATIONS WILL BE RETURNED TO APPLICANT.

RETURN ALL COPIES

CLASS III PERSONAL USE APPLICATION AND QUESTIONNAIRE

Issued Under Authority of the Wildlife Code of the State of Florida

(Chapter 68A, Florida Administrative Code)

FLORIDA FISH AND WILDLIFE CONSERVATION COMMISSION

FWCDLE 621 (08/08)

THIS PERMIT DOES NOT ALLOW FOR THE POSSESSION OF THE FOLLOWING WILDLIFE:

Class I Wildlife:

1. Chimpanzees (genus Pan) 2. Gorillas (genus Gorilla)

3. Gibbons (genus Hylobates) 4. Drills and Mandrills (genus Mandrillus)

5. Orangutans (genus Pongo) 6. Baboons (genus Papaio)

7. Siamangs (genus Symphalangus) 8. Gelada baboons (genus Theropithecus)

9. Snow leopards (Panthera uncia) 10. Leopards (Panthera pardus)

11. Jaguars (Panthera onca) 12. Tiger (Pathera tigris)

13. Lions (Panthera leo) 14. Bears (family Ursidae)

15. Rhinoceros (family Rhinocerotidae) 16. Elephants (family Elephantidae)

17. Hippopotamuses (family Hippopotamidae) 18. Cape Buffalos (Syncerus caffer caffer)

19. Crocodiles (except dwarf and congo) (family

Crocodilidae)

20. Gavials (family Gavialidae)

21. Black caimans (Melanosuchus niger) 22. Komodo dragons (Varanus komodoensis)

Class II Wildlife:

1. Howler monkeys (genus Alouatta) 2. Uakaris (genus Cacajao)

3. Mangbeys (genus Cercocebus) 4. Guenons (genus Ceropithecus)

5. Bearded sakis (genus Cercocebus) 6. Guereza monkeys (genus Colobus)

7. Celebes black apes (genus Colobus) 8. Idris (genus Indri)

9. Macaques (genus Macaca) 10. Langurs (genus Presbytis)

11. Douc langurs (genus Pygathrix) 12. Snub-nosed langurs (genus Phinopithecus)

13. Proboscis monkeys (genus Nasalis) 14. European and Canadian lynx (Lynx lynx)

15. Servals (Leptaillurus serval) 16. Cheetahs (Acinonyx Jabatus)

17. Cougars panthers (Puma concolor) 18. African golen cats (Profelis aureta)

19. Bobcats (Lynx rufus) 20. Fishing cats (Prionailurus viverrina)

21. Caracals (Characal caracal) 22. Clouded leopards (Neofelis nebulosa)

23. Ocelots (Leopardus pardalis) 24. Gray wolves (Canis lupus) (including Wolf X domestic hybirds

which are 25 percent or less domestic dog).

25. Coyotes (Canis latrans) 26. Asiatic jackals (Canis aureus)

27. Red wolves (Canis niger) (including wolf x domestic

hybrids which are 25 percent or less domestic dog)

28. Side-striped jackals (Canis adustus)

29. Black-backed jackals (Canis mesomelas) 30. African hunting dogs (Lycaon pictus)

31. Indian dholes (Cuon alpinus) 32. Honey badgers (Mellivors capensis)

33. Wolverines (Gulo gulo) 34. Old World badgers (Meles meles)

35. American badgers (Taxides taxus) 36. Hyenas (all species) (family Hyaenidae)

37. Binturongs (Arctictis binturong) 38. Alligators, caimans (except Alligator mississippiensis) (family

Alligatoridae)

39. Dwarf crocodiles (Osteolaemus tetraspis) 40. Ostrich (Struthio camelus)

41. Cassowary (Casuarius spp.)

FWCDLE 621 (08/08)

FLORIDA FISH AND WILDLIFE CONSERVATION COMMISSION

PERSONAL USE QUESTIONNAIRE

Please print with blue or black ink only

Name: Age:

Address:

City State Zip Code

Phone Number(s): (H) ( ) – (W) ( ) –

The answers on this questionnaire indicate my knowledge about the habits, requirements, diet, health care and exercise needs of

the animal(s) I plan to possess, as required under Florida Administrative Code 68A-6.0022. I understand my permit may be denied or

revoked if I fail to meet the requirements of 68A-6.0022, F.A.C.

Signature Date

The following questions will be used to evaluate your knowledge of and experience with the animals you plan to possess.

This information will be used to determine the approval or denial of the permit for which you are applying. Please attach

additional pages as necessary.

1. What are the common names of the animals you plan to possess?

2. What are the scientific names of the animals you plan to possess? (Genus/species)

3. In what continent and country do the animals occur naturally in the wild?

4. How large (length, height, etc.) will these animals get when they are adults?

5. What is the average weight of the animals when they reach sexual maturity? (Approximately in pounds)

FWCDLE 621 (08/08)

6. What do the animals eat in the wild?

7. What foods are available to you to feed your animals while in captivity?

8. How much do theses animals eat, as an adult, per day?

9. Are the animals you plan to possess social or solitary animals in the wild (excluding the mating season)?

10. What are the Florida Fish and Wildlife Conservation Commission's standard caging requirements for the animals you plan to

possess?

11. What are the additional safety requirements you must meet to maintain the animals as personal pets?

12. What is the name of the veterinarian you intend to use for the health care of your animals?

Name: Phone: ( ) –

Address:

City State Zip Code

13. What is the address and telephone number of the closest office of the Florida Fish and Wildlife Conservation Commission office

that you can contact regarding the lawful keeping of your animals?

14. What is the name, address and license number (if in Florida) of the source of your wildlife? (It is unlawful to purchase wildlife from

an unpermitted entity in Florida) [You must have documentation of the source and supplier of your animals]

15. If your animals escape from their cage, enclosure, tether, or leash, are you required to report the incident to the Florida Fish and

Wildlife Conservation Commission? Yes No

16. If your animals bite or scratch an individual, are you required to report the incident to the Florida Fish and Wildlife Conservation

Commission? Yes No

FWCDLE 619 Instructions (02/06); Revised (06/09)

Incorporated by reference in Rules 68A-6.0022, 68A-6.003, and 68A-6.007, F.A.C.

Page 1 of 3

CAPTIVE WILDLIFE CRITICAL INCIDENT/DISASTER PLAN

INSTRUCTIONS

This two part form is to be completed and submitted or retained on file as indicated:

 Part-A: To be completed and submitted with the initial or renewal application requesting authorization for

the possession of captive wildlife.

 Part-B: To be completed and retained at the licensed premises where wildlife is housed or maintained. Part-

B of the Captive Wildlife Critical Incident/Disaster Plan shall be made available upon request to

Commission personnel. All employees and/or volunteers should be informed of the facilities critical

incident/disaster plan.

PART-A: Submitted with application for initial or renewal license/permit. Please print form with responses.

I. Applicant or Licensee Information:

NAME: Enter full name as indicated on the application for a license/permit requesting authorization for the

possession of captive wildlife.

PHONE NUMBER: Enter emergency contact phone numbers for the applicant or licensee including business,

home and/or cellular as applicable.

BUSINESS NAME: Enter Business name, if applicable, as indicated in the application for a license/permit

requesting authorization for the possession of captive wildlife.

MAILING ADDRESS: Enter complete mailing address including City, State and Zip Code as indicated on the

application for a license/permit requesting authorization for the possession of captive wildlife.

II. Facility Information: (Location where wildlife is maintained)

FACILITY ADDRESS: Enter the complete address for the facility location as indicated in the application for a

license/permit requesting authorization for the possession of captive wildlife.

GPS COORDINATES: Enter the GPS coordinates in Degree, Minutes, and Seconds format for the facility’s main

entrance/exit. Leave blank if the coordinates are unknown.

III. Emergency Contact (Individual that does not reside at the facility location)

NAME: Enter the name of an individual responsible for assisting with emergency response or that may assist in

providing contact information for the licensee/permittee in the event of a critical incident or disaster.

BUSINESS NAME: Enter the business name for the emergency contact if applicable.

MAILING ADDRESS: Enter the complete address including City, State and Zip Code for the individual responsible

for assisting with emergency response or that may assist in providing contact information for the licensee/permittee

in the event of a critical incident or disaster.

PHONE: Enter emergency contact phone numbers for another individual responsible for assisting with emergency

response or that may assist in providing contact information for the licensee/permittee in the event of a critical

incident or disaster. Include business, home and/or cellular numbers as applicable.

IV. Veterinarian Contact Information

NAME: Enter the name of the Veterinarian used to provide veterinary services for wildlife maintained at this facility.

BUSINESS NAME: Enter the Business name or clinic name for your Veterinarian.

MAILING ADDRESS: Enter the complete address including City, State and Zip Code for Veterinarian or Animal

Clinic used to provide veterinary services for wildlife maintained at this facility.

FWCDLE 619 Instructions (02/06); Revised (06/09)

Incorporated by reference in Rules 68A-6.0022, 68A-6.003, and 68A-6.007, F.A.C.

Page 2 of 3

PHONE: Enter contact phone numbers for the Veterinarian or Animal Clinic used to provide veterinary services for

wildlife maintained at this facility. Include business and/or cellular numbers as applicable.

PART-B: This Part is to be kept at the facility location and made available for inspection.

I. Emergency Plan

Enter a detailed plan that specifies what to do (who, what, where, when and how) in the event of a disaster and

critical incident, to include:

Levels of Action (Pre-event, Event, and Post-event)

Action plan for securing wildlife on site.

Action plan for evacuation including:

o Stating where all wildlife will be located and providing location and contact information.

o State how long the wildlife may be maintained at this location.

Action plan for re-entry to facility.

All employees and/or volunteers at the facility are to be familiarized with the emergency plan.

II. Capture and Transport Equipment Inventory:

CHEMICAL CAPTURE EQUIPMENT: Enter a detailed list of all equipment utilized for chemical capture (including

drugs, delivery systems and supplies) and the location where this equipment is stored.

EMERGENCY CONTACT INFORMATION: Enter the emergency contact information (including name, complete

address, and contact phone number(s)) for the person(s) authorized to utilize such equipment. Attach additional

sheets as applicable.

PHYSICAL CAPTURE EQUIPMENT: Enter a detailed list of all equipment utilized for physical capture (including

catch poles, nets, tongs, and other capture equipment) and the location where this equipment is stored.

EMERGENCY CONTACT INFORMATION: Enter the emergency contact information (including name, complete

address, and contact phone number(s)) for the person(s) authorized to utilize such equipment. Attach additional

sheets as applicable.

TRANSPORT CAGES AND VEHICLES: Enter a detailed list of all equipment utilized to temporarily house and/or

transport wildlife, and the location where this equipment is stored.

EMERGENCY CONTACT INFORMATION: Enter the emergency contact information (including name, complete

address, and contact phone number(s)) for the person(s) authorized to utilize such equipment. Attach additional

sheets as applicable.

III. Facility Information Checklist:

Attach supporting documentation that includes a schematic or graphic depiction of the facility indicating the location

of the following, as applicable:

All facility access points (entrance(s) and exit(s)), diagram(s) of areas where wildlife is housed, location where

emergency supplies are stored, location of each electrical and gas shut-off switch/valve.

IV. Miscellaneous Emergency Supplies Checklist:

Check applicable boxes or list any other miscellaneous emergency supplies. Document location where supplies

are stored or contact information for obtaining supplies.

FWCDLE 619 Instructions (02/06); Revised (06/09)

Incorporated by reference in Rules 68A-6.0022, 68A-6.003, and 68A-6.007, F.A.C.

Page 3 of 3

V. Current Animal Inventory

Attach a complete inventory of the wildlife maintained at the facility location. Include the total number of each

species and any identifying methods (microchip number(s), tattoo(s), mark(s), scar(s), etc.).

PART-B is to be kept on file at the facility location and made available for inspection upon request of

Commission personnel.

FWCDLE 619 (02/06); Revised (06/09)

Incorporated by reference in Rules 68A-6.0022, 68A-6.003, and 68A-6.007, F.A.C. Page 1 of 5

FLORIDA FISH AND WILDLIFE CONSERVATION COMMISSION

DIVISION OF LAW ENFORCEMENT

CAPTIVE WILDLIFE CRITICAL INCIDENT/DISASTER PLAN

PART A: Complete and submit with initial or renewal application for license/permit. Please Print.

I. Applicant or Licensee Information:

Name:

Phone:

( )

Business Name:

Phone:

( )

Mailing Address:

City

State

Zip Code

II. Facility Information: Location where wildlife is maintained

Facility Address:

City

State

Zip Code

GPS Coordinates

Flood Zone:

Yes

III. Emergency Contact: (Person not living at facility location)

Name:

Phone:

( )

Business Name:

Phone:

( )

Mailing Address:

City

State

Zip Code

IV. Veterinarian Contact Information:

Veterinarian:

Name:

Phone:

( )

Business Name:

Phone:

( )

Mailing Address:

City

State

Zip Code

I certify that as part of the critical incident/disaster plan, Part B of this form is maintained on file at the facility location where wildlife is

housed or maintained. Furthermore said information will be made available for inspection upon request of commission personnel. Said

information indicates a detailed emergency plan, inventory of capture and transport equipment, and a schematic or graphic depiction of

the facility.

Name (Print)

Signature

Date

FWCDLE 619 (02/06); Revised (06/09)

Incorporated by reference in Rules 68A-6.0022, 68A-6.003, and 68A-6.007, F.A.C.

Page 2 of 5

PART B: To be retained on file at the facility location and made available for inspection

I. Emergency Plan (Attach additional sheets as necessary)

Specific plan of action to be taken in the event of an emergency (natural disaster, fire, etc.) and critical incident:

FWCDLE 619 (02/06); Revised (06/09)

Incorporated by reference in Rules 68A-6.0022, 68A-6.003, and 68A-6.007, F.A.C.

Page 3 of 5

II. Capture and Transport Equipment Inventory

A. Chemical Capture Equipment ( ) Not Applicable

Emergency Contact Information:

Name:

Phone:

( ) –

Address:

Phone:

( ) –

City

State

Zip Code

B. Physical Capture Equipment

(nets, catch poles, gloves, hooks, tongs, etc.)

Emergency Contact Information:

Name:

Phone:

( ) –

Address:

Phone:

( ) –

City

State

Zip Code

Transport Cages and Vehicles

Emergency Contact Information:

Name:

Phone:

( ) –

Address:

Phone:

( ) –

City

State

Zip Code

FWCDLE 619 (02/06); Revised (06/09)

Incorporated by reference in Rules 68A-6.0022, 68A-6.003, and 68A-6.007, F.A.C.

Page 4 of 5

III. Facility Information Checklist

(Attach photo or drawing depiction of the facility lay out to indicate the following)

Site plan of facility

Location of access points to facility if access is controlled by fences, gates, etc.

Location of area(s) where captive wildlife is kept

Location of supplies (food, medicines, capture equipment, etc.)

Location of each electricity and gas shutoff switch/valve

IV. Miscellaneous Emergency Supply Checklist

Food

Water

Medical Supplies

Generator(s)

Ice

Misc. Supplies

Location of storage and/or contact information for obtaining supplies

V. Current Animal Inventory (Attached)

FWCDLE 619 (02/06); Revised (06/09)

Incorporated by reference in Rules 68A-6.0022, 68A-6.003, and 68A-6.007, F.A.C.

Page 5 of 5

Northwest Region North Central Region

3911 Hwy. 2321 3377 E. US Highway 90

Panama City, FL 32409-1658 Lake City, FL 32055-8795

(850) 265-3676 (386) 758-0525

24-Hour Law Enforcement: 24-Hour Law Enforcement:

(850) 245-7710

386-758-0529

Northeast Region Southwest Region

1239 S.W. 10th Street 3900 Drane Field Road

Ocala, FL 34474-2797 Lakeland, FL 33811-1299

(352) 732-1225 (863) 648-3203

24-Hour Law Enforcement: 24-Hour Law Enforcement:

352-732-1228

863-648-3200

South Region Monroe and Collier County

8535 Northlake Boulevard 24-Hour Law Enforcement:

West Palm Beach, FL 33412 305-289-2320

(561) 625-5122

24-Hour Law Enforcement:

561-625-5122

State Warning Point

Florida Department of Agriculture and Consumer Services

Emergency: 1-800-320-0519 or 850-413-9911 Division of Animal Industry

Non Emergency: 850-413-9900 850-410-0900

www.floridadisaster.org

www.flsart.org

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