LIVE BAIT DEALER'S LICENSE APPLICATION R12-4-411 · 2019-11-04 · Attachments: Additional...
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FORM 2711-A Revised 1/17 FOLE FOR DEPARTMENT USE ONLY Date Received Region: Date Review Complete Approved: Denied: Valid From: To: Approved By: Date: ARIZONA GAME AND FISH DEPARTMENT LIVE BAIT DEALER'S LICENSE APPLICATION R12-4-411 [PLEASE PRINT OR TYPE] FEE: $35.00 NEW or RENEWAL Date of Birth Department ID Number or SSN: Name Mailing Address City State Zip Phone Gender Weight Height Hair Eyes Email Resident Non Resident Calendar Year ______ Number of Yrs Resident Business Location where aquatic wildlife will be held and sold (one application per place of business): Phone Mailing Address City State Zip Federal Tax ID # Business Name Species and numbers to be held and sold per year: Fathead Minnow Mosquito fish Waterdogs Threadfin Shad Golden Shiner Goldfish Supplier Name Zip State Mailing Address Phone Suppliers Federal Tax ID # City Attachments: Additional information required under R12-4-417 Detailed description/diagram of facilities where wildlife will be held Fish Disease Certification -Specified in Disease Stipulations Procedures to comply with R12-4-428
Transcript of LIVE BAIT DEALER'S LICENSE APPLICATION R12-4-411 · 2019-11-04 · Attachments: Additional...
FORM 2711-A Revised 1/17 FOLE
FOR DEPARTMENT USE ONLY
Date Received Region:
Date Review Complete Approved: Denied:
Valid From: To:
Approved By: Date:
ARIZONA GAME AND FISH DEPARTMENT LIVE BAIT DEALER'S LICENSE APPLICATION
R12-4-411
[PLEASE PRINT OR TYPE] FEE: $35.00
NEW or RENEWAL
Date of BirthDepartment ID Number or SSN:
Name Mailing AddressCity State Zip Phone
Gender Weight Height Hair EyesEmail
ResidentNon Resident
Calendar Year
______ Number of Yrs Resident
Business Location where aquatic wildlife will be held and sold (one application per place of business):
Phone Mailing Address City State Zip
Federal Tax ID #
Business Name
Species and numbers to be held and sold per year:
Fathead Minnow
Mosquito fish WaterdogsThreadfin Shad
Golden Shiner Goldfish
Supplier Name
Zip StateMailing Address Phone
Suppliers Federal Tax ID # City
Attachments: Additional information required under R12-4-417Detailed description/diagram of facilities where wildlife will be heldFish Disease Certification -Specified in Disease StipulationsProcedures to comply with R12-4-428
FORM 2711-A Revised 1/17 FOLE
***LICENSE EXPIRES DECEMBER 31 OF EACH YEAR, RENEWAL APPLICATIONS MUST BE RECEIVED OR POSTMARKED BY DECEMBER 31st ***
Date APPLICANT SIGNATURE: I certify the information provided on this application is true and correct to my knowledge. I will comply with any municipal, county, state, or federal code, ordinance, statute, regulation or rule applicable to this license and that my live wildlife privileges are not currently suspended or revoked in this state, any other state or territory, or by the United States.
In accordance with provisions under Section 41-1030, Arizona Revised Statutes: An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by a statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or condition. This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable attorney fees, damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section. A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal pursuant to the Agency's adopted personnel policy. This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.
