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REGULATED PRIVATE SHOOTING PRESERVE REPORT Submit this completed form to: Wildlife Division, Bureau of Natural Resources, Department of Energy & Environmental Protection, 79 Elm Street, Hartford, CT 06106. Name of Permit Holder: Permit No.: No. of Acres: Town: Sec. 26-48-7. Identification and records of game shot (b) The permittee shall keep accurate, written, daily records which shall be open to inspection by any duly authorized representative of the Department at any reasonable time. These records shall include (1) the name of each person hunting on the area, the day the person was hunting and the amount of game, pheasant, quail, chukar partridge, and ducks taken each day. (2) The number of all pheasants, quail, chukar partridge, and ducks liberated on the area included in the permit, together with the dates when such birds were liberated. Not later than thirty days following the period for which the permit was issued, the permittee shall submit to the department a true copy of his records on forms provided by the department. Any person making a written false statement on this form shall be subject to arrest as provided for in Section 53a-157 of the Penal Code. Signature:_________________________________________ Date: DATE Number of Hunter(s) Pheasant Lib Quail Lib Chukar Lib. Ducks Lib. 79 Elm Street, Hartford, CT 06106-5127 www.ct.gov/deep Affirmative Action/Equal Opportunity Employer DEEP-SHOOTING-REPORT-010 Page 1 of 2 REV. 7/11/2014
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79 Elm Street, Hartford, CT 06106-5127www.ct.gov/deepAffirmative Action/Equal Opportunity Employer

DEEP-SHOOTING-REPORT-010Page 1 of 2REV. 7/11/2014

79 Elm Street, Hartford, CT 06106-5127www.ct.gov/deepAffirmative Action/Equal Opportunity Employer

DEEP-SHOOTING-REPORT-010Page 2 of 2REV. 7/11/2014

REGULATED PRIVATE SHOOTING PRESERVE REPORT

Submit this completed form to: Wildlife Division, Bureau of Natural Resources, Department of Energy & Environmental Protection, 79 Elm Street, Hartford, CT 06106.

Name of Permit Holder:      

Permit No.:      No. of Acres:      Town:     

Sec. 26-48-7. Identification and records of game shot

(b) The permittee shall keep accurate, written, daily records which shall be open to inspection by any duly authorized representative of the Department at any reasonable time. These records shall include (1) the name of each person hunting on the area, the day the person was hunting and the amount of game, pheasant, quail, chukar partridge, and ducks taken each day. (2) The number of all pheasants, quail, chukar partridge, and ducks liberated on the area included in the permit, together with the dates when such birds were liberated.

Not later than thirty days following the period for which the permit was issued, the permittee shall submit to the department a true copy of his records on forms provided by the department.

Any person making a written false statement on this form shall be subject to arrest as provided for in Section 53a-157 of the Penal Code.

Signature:_________________________________________ Date:     

DATE

Number of Hunter(s)

Pheasant

Lib Harv.

Quail

Lib Harv.

Chukar

Lib. Harv.

Ducks

Lib. Harv.

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

DATE

Number of Hunter(s)

Pheasant

Lib Harv.

Quail

Lib Harv.

Chukar

Lib. Harv.

Ducks

Lib. Harv.

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

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****TOTAL****

If additional sheets are needed, please write or call (860) 424-3011


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