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Analise Lindborg
Bureau of Natural Heritage Conservation
PO Box 7921
Madison WI 53707-7921
608-261-6449

Endangered and threatened species permit Annual report

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 there are multiple permit holders working jointly on a project, a single report may be submitted for the project. The report must include all names and permit numbers for the individuals whom the joint report covers.

Failure to submit timely, complete and/or accurate annual reports may result in revocation 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 12/12)
E/T Annual Report Form

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.
Report submission
Submit the following materials to Analise Lindborg at the email or address below to fulfill the annual report requirement of your permit :

  • 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
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