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Analise Lindborg
E/T Permit Coordinator
Bureau of Natural Heritage Conservation
PO Box 7921
Madison WI 53707-7921
608-261-6449

Endangered and threatened species permit Annual report and renewal application

All holders of Wisconsin endangered and threatened species (E/T) permits are required to complete and submit an annual report of activities conducted under the permit, including any and all information specifically requested by the department pursuant to s. 29.604, Wis. Stats., and Chapter NR 27, Wis. Admin. Code. If you hold more than one E/T permit, please submit a separate annual report for each permit.

Failure to submit timely, complete and/or accurate annual reports may result in non-renewal of the permit and confiscation of any endangered or threatened animals, plants, or specimens in your possession.

Rare species data collected from permit holders and applicants may be added to the Wisconsin Natural Heritage Inventory database. Personal information collected on this form will be used for administrative purposes and may also be made available to requestors under Wisconsin's Open Records law [ss. 19.31-19.39, Wis. Stats.].

Form 1700-012 (R 11/08)

Permit holder information
Name
Organization
E/T Permit number
Street address
City:
State
Zip code
Telephone number
Cell phone number
Email
Permit work information
Please check one of the following boxes:
I hereby report that no work was conducted** under the authority of this permit during the past year. I am submitting this form as my annual report (no supplementary materials are required).
I hereby report that work was conducted** under this permit during the past year.
** "Work conducted" includes any activity with listed species authorized under this permit, including possession in captivity.
Annual Report Submission
Submit the following materials to Analise Lindborg at the email or address below to fulfill the annual report requirement of your permit (this information is required regardless of whether or not you wish to renew the permit for the coming year):

  • If you did not conduct any work or activities under your E/T permit, please complete and submit the Annual Report Form only. Supplementary information is not required; or
  • If you did work under your E/T permit, please complete and submit the Annual Report Form and a supplementary attachment describing your work with listed species over the past year. See the report instructions [PDF] for details.
Mail Email Fax
E/T Permit Coordinator
Bureau of Natural Heritage Conservation
PO Box 7921
Madison WI 53707-7921
Fax: (608) 266-2925
Permit renewal
Would you like to request renewal of your permit for the next 5 years?
No. I hereby request my permit be closed.
Yes. I hereby request renewal of this permit for the next five years. I will mail my $100 fee separately.

If renewing your permit, please use the space below to describe what should be covered under this permit for the coming years. Include specific activities, species names and numbers, location(s) of work or activities, where species or specimens will be kept (address, if different from permit holder's address) and the final disposition of species or specimens (released, kept in captivity, outplanted, sold, etc.). Additional documents and images should be sent to Analise Lindborg at the email or address below. Upon review and approval of this information and your permit records, you will be issued an updated E/T permit.
Renewal Application Submission
Submit the following materials to Analise Lindborg at the email or address below to apply for renewal of your E/T permit:

  • This completed form;
  • Supplemental information to the description of your permit activities above; and
  • $100 fee (payable to the Bureau of Natural Heritage Conservation). Invoices can be issued upon request.
Mail Email Fax
E/T Permit Coordinator
Bureau of Natural Heritage Conservation
PO Box 7921
Madison WI 53707-7921
Fax: 608 266-2925
Notes

By entering my initials, and today's date below, pursuant to the provisions of s. 29.604, Wis. Stats., and Chapter NR 27, Wis. Admin. Code, I do hereby submit this form and any attached or corresponding information to fulfill the annual reporting requirement of my Wisconsin Endangered and Threatened Species Permit. I certify that I am the person submitting this information and that any statements made on or in conjunction with this form and any attached or supplementary materials are complete, correct, and not misrepresented in any way.

Initials:          Today's Date:


Last revised: Monday, October 02, 2017