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OREGON Oregon Department of Fish and Wildlife <br />Wildlife Division - Wildlife Permits <br />3406 Cherry Avenue NE <br />Salem OR 97303-4924 <br />Phone: (503) 947-6303 <br />flthdWlltlltte Fax: (503)947.6330 <br />Scientific Taking Permit Application <br />Birds, Mammals, Amphibians and Reptiles <br />FOR OFFICIAL USE ONLY <br />Permit No. <br />Dale <br />Payment <br />Annual Report <br />Calendar Year: 2 D 10 <br />FIRST-TIME APPLICATION ❑X RENEWAL <br />- <br />Complete regardless of fast time application or renewal <br />P <br />i <br />' <br />it <br />b <br />ous year <br />rev <br />s perm <br />num <br />er <br />Name Brian Meiering <br />(Enclose <br />reviou <br />ear's <br />it <br />p <br />s y <br />perm <br />) <br />Affiliation <br />Mailing Address 1568 Canal St <br />Federal permit number if applicable <br />Attach copy of federal permit <br />Springfield OR 97477 <br />Ciry State ZIP <br />Social Security Number 525-49-BD27 <br />tY <br />Permit Fee - $102.00* <br />PAYMENT METHOD: Check or Money <br />(Required by federal and state law) <br />Order Only <br />Phone 541. 741.2032 <br />*Please return this form along with a <br />check or money order for $102.00 to <br />Fax 541.465.4722 <br />ODFW at the above address. <br />E-mail brianmeiering@corncaet.net <br />Permit expires December 31 <br />. <br />I wish to ❑ Collect and/or remove from wild ® Handle, live-trap, mark and/or release <br />Salvage (collect dead specimens) <br />Please list below all species you anticipate handling, this section must be filled out regardless of first time <br />application or renewal. List all sub-permitees on a separate piece of paper. <br />Number <br />Species/Common Name <br />Specific Location (County) <br />Method <br />20 <br />Pacific Tree frog <br />Lane, Benton, Linn, Douglas <br />seine, dip net, <br />20 <br />Red-Legged frog <br />Lane', Benton,. Linn, Douglas <br />seine, dip net, <br />hand tore. <br />20 <br />Northwestern Pond turtle <br />Lane, Benton, Linn, Douglas <br />seine, dip net, <br />hand capture, <br />Other Reptiles (each ep) <br />Lane, Benton, Linn, Douglas <br />seine, dip net, <br />hand ca tore <br />350 <br />Other Amphibians (each sp) <br />Lane, Benton, Linn, Douglas <br />seine, sip net, <br />hand capture, <br />If you are a teacher, do you intend to use the permit for students collecting on supervised field trips? <br />❑ Yes ❑ No (Students collecting on their own must possess their own permit) <br />Please attach separate page(s) summarizing your research project or otherwise substantiate your need for a <br />taking permit. This information must be submitted regardless of whether this is a first time application or a <br />renewal. In addition, if you are a student, provide the name, address and telephone number of your sponsoring <br />professor and the degree you are working-toward. Submit copy of federal permit and approval from The <br />Institutional Animal Care and Use Committee (IACUC). <br />/ & 's 9/18/2010 Environmental Specialist <br />Applicant Signature Date Occupation or Affiliation <br />* $2.00 agent fee per ORS 497.022. Permit Stipalaliotts on back <br />cdt08/19/09 <br />