FEE $63.

00
Make Check Payable to DEEP

Wildlife Division 79 Elm Street Hartford, CT 06106 APPLICATION FOR REGULATED PRIVATE SHOOTING PRESERVE PERMIT Connecticut General Statutes Section 26-48 and regulations 26-48-(1-11)
1. The preserve will be located in the following town (s): 2. Total number of acres to be included in the permit Number of acres owned by undersigned Number of acres under lease or agreement 3. Names of property owners whose land is under lease or agreement for hunting: Name Address Acres

4. Preserve will be operated as:

Private Preserve (members and/or guests only) Commercial Preserve (hunting permitted on payment of fee) No No No

5. Is the total acreage in a single block? Yes

6. Is a residence maintained on the property by the undersigned? Yes 7. Is a game farm operated in connection with this property? Yes 8. Will game be raised on the property for liberation? Yes No No

9. Will game be purchased for liberation on this property? Yes 10. Type of game to be included in permit: a. Pheasants b. Quail c. Chukar Partridge 11. Will shooting be done on Sunday under this permit? Yes

d. Ducks No

(if the answer is yes, a statement signed by the proper town authorities that Sunday shooting will be permitted, MUST be filed with the Commissioner. After a statement has been filed once, it will be considered to remain in force until canceled by the proper town authorities.)

12. I would like to order tags @ .20 cents per tag. Note: A check for $63.00 (permit fee) plus $ _______ fee for tags must accompany this application. 13. A map showing the external boundaries of the acreage to be included in the permit MUST accompany this application. I have read the laws and regulations pertaining to private shooting preserves and am familiar with their provisions. Name:
(Please Print)

Signed: Address: Email Address: Date of Application: _____________

Acting for Club: Telephone Number:

Rev. 7/12/2011