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Florida Fish and Wildlife Conservation Commission

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Florida Fish and Wildlife Conservation Commission
Application for
ESC - LICENSE TO POSSESS CLASS III WILDLIFE FOR EXHIBITION OR PUBLIC SALE --- $50.00
P.O. Box 6150, Tallahassee, FL 32314-6150
(850) 488-6253
New Applicant – yes no
Business Name E-mail Address
Mailing Address City State Zip
Facility Address City State Zip
County (where the facility is located) Business Phone ( _)
Note: Corporations or Fictitious Names must be registered
COMMERCIAL ACTIVITY: (check all applicable)
Pet Shop
Exhibition of Wildlife: Permanent Exhibit Mobile Exhibit (attach 12 month itinerary)
Sale of Wildlife: _ Non-Venomous Reptiles or Amphibians
Venomous Reptiles (Additional License Required) Mammals Birds
INVENTORY OF ANIMALS (Attach Completed Inventory Page – ESC)
All applicants (new or renewal) must provide an inventory of the animals that you are requesting the authority to possess
REQUIRED DOCUMENTATION: CRITICAL INCIDENT/DISASTER PLAN
All Applicants (new or renewal) must provide Part A of their Critical Incident/Disaster Plan.
REQUIRED DOCUMENTATION: CAPUCHIN, SPIDER & WOOLLY MONKEYS - New applicants must attach the following:
Documentation of experience from applicant 2 Letters of Reference
I swear and affirm that the information provided is true and correct. I agree to adhere to the provisions of Chapter 379 Florida
Statutes, and the rules and regulations of the Commission pertaining to the possession of wildlife. I understand that my wildlife
facilities are subject to inspection by Commission personnel as required by Florida Statute.
/ /
Owner/Contact Name (Please Print) Home Phone Owner/contact Name (Signature) MM DD YY
Date of Birth / / Social Security # Sex Race Height ft in
FOR COMMISSION USE ONLY:
Approved by
Denied by
Date
Date
Code:
Reason:
INCOMPLETE APPLICATIONS WILL BE RETURNED
App ID (if renewal) ______________
INSTRUCTIONS FOR COMPLETING APPLICATION
BIOGRAPHICAL DATA
Complete all information in this section. The information must pertain to the person (possessor, manager or owner) applying to
possess the wildlife. Corporations or Fictitious Names must be officially registered. The facility address, including the county,
should indicate the physical location where the wildlife is to be housed or possessed. The Florida Fish and Wildlife Conservation
Commission (FWC) collects social security number (SSN) for the issuance of recreational and professional wildlife, fishing or
hunting licenses or permits to an individual in accordance with s. 379.352F.S. and 42 USC 666 for the purposes of administration
of the Title IV-D program for child support enforcement, use by the commission, and as otherwise provided by law.
COMMERCIAL ACTIVITY
Check the appropriate box(es), which best describes your intended activity. All traveling acts and exhibits must attach a 12-month
itinerary. Additional permits are required for wildlife rehabilitation and possession or exhibition of venomous reptiles.
INVENTORY
Complete the inventory page(s) attached to the application. Indicate the number of each species that you currently possess by
entering the quantity in the “QTY” field. For species that you plan to possess put a “P” in the “QTY” quantity field. For species that
you currently possess but do not house in Florida put a zero (0) in the “QTY” field.
REQUIRED DOCUMENTATION FOR CRITICAL INCIDENT/DISASTER PLAN
Critical Incident/Disaster Plan:
A completed Part A (first page) must be attached with each initial and renewal application.
REQUIRED DOCUMENTATION FOR CAPUCHIN, SPIDER & WOOLLY MONKEYS
Documentation of Experience:
In order to possess capuchin, spider or woolly monkeys, the applicant must meet the experience requirements for Class II
Wildlife. Documentation of such experience shall include a description of the specific experience acquired, dates and times
experience was obtained and the specific location(s) where acquired.
CLASS II: Applicants must document no less than one (1) year of substantial practical experience (to consist of no less than
1,000 hours) as described above, or demonstrate 500 hours of substantial practical experience and successfully complete a
written examination (80%) which is administered by the Division of Law Enforcement. Application should not be submitted
until notification by FWC that you have passed the exam.
References:
Attach two letters of reference from individuals having personal knowledge of your stated experience. Only one reference
letter may be from a relative. One reference letter must be from an individual licensed by FWC for wildlife of the same or
higher class and family or a professional organization or governmental institution.
Failure to complete the application will result in application being returned and/or denied.
ESC – INVENTORY PAGE BUSSINESS NAME:
WILDLIFE THAT YOU CURRENTLY POSSES IN FLORIDA: Please indicate the exact number of species you currently
possess in the “QTY” field. If you do not house these species in Florida, put a zero (0) in the “QTY”.
WILDLIFE THAT YOU DO NOT POSSESS IN FLORIDA: For the species that you do not currently possess but plan to
possess put a “P” in “QTY”. For species that you possess but do not house in Florida, put a zero (0) in “QTY”.
Please list all animals by species (except Capuchin, Spider, and Woolly Monkeys) in the species list.
Class III
CODE
QTY
SPECIES LIST
Capuchin Monkey
MA1
Spider Monkey
MB3
Woolly Monkey
MB2
All other Class III Mammals
(complete species list)
M7
All Class III Reptiles/Amphibians
(complete species list)
V
All Class III Birds
(complete species list)
U
Venomous Reptiles*
(complete species list)
Z
*A License to Possess and/or Exhibit Venomous Reptiles/Reptiles of Concern is also required.
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
No
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
C. 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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Completed 2 August 2021

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