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Jul. 18, 2011 1:42PM <br />FAX 541 682 4874 COE PWM BLDG #2 <br />A TTN. ODFW ESA PERMIT STAFF <br />(Joy Vaughan, Sionne Nesbit) <br />Oregon Fish Sc Take Permit Fee Form <br />I ABREE To P V ABOVE No N1 <br />.jgCORDINO TO CARD ISSUER ABREEINT <br />MERC HANT COPY <br />. O r egon Scionfifie Take Per Fee Schedule <br />fee of $ 7. (includes a $2.00 license agent fee) shall be charged for each Fish So lentific Take <br />Pewit issued for soientifit or educational purposes as part of e p rogram o c ourso of study at a - <br />educational Institution. <br />fee of $1 .o l a $2,00 license agent fee shall be charged for eac Fish Scientific <br />'Fake Peimit fo any agency, corporation, association, o r other su ch entity. <br />Amount nelue , q La <br />You oan submit your payment by ohe ck, monoy order o cr edit card, To submit your payment <br />by check (please include the permit num your check), submit this completedfor <br />with Check to <br />O R Dept; of Fish, Widli <br />A ttn: Fiscal Department <br />3408 Cherry Ave NE <br />S alem, OR 97303 <br />947- <br />To w <br />r it ' our payment by credit card, please fax this form to 5o ,, + , 3- <br />6113 with the information Wow; Type of card (Vise or Mastercard), NW-LICEN <br />Name o n card i t <br />N umber : Card •° *TT., <br />Expiration Dates k <br />F <br />Zip Code of card Wider: I qQj <br />No. 0618 P. <br />OR DEPT FISH DJF 0801 <br />$406 CHERRY U HE <br />Dep NE RWHI #; 95OV251 <br />SALIet 25 ,i <br />R 1 268e27 )3 <br />E JUL ion 11 TII s' <br />x�[s 060894'` <br />AUS RESPONSE: H <br />O MICH ON ADORES$ OR ZIP <br />TOTA <br />M <br />if„ �nw�.r wr+ w.�� rwt wr +►w wwaaaaarr� -�w� R,+ r, r rar <br />1 <br />T <br />,12 w <br />Deceived Time Jul, 18, 2011 1:39PM No,7107 <br />