Every order passed on the application shall be communicated to the applicant either in person or by registered post free of cost.
Form
Application under Section 40-A of Wild Life (Protection) Act, 1972 for certificate of ownership
To,
The Chief Wild Life Warden or the Authorised Officer
State or Union Territory of .
.
| (i) I, |
. |
. |
| (Surname) |
(First Name) |
(Middle Name) |
| son/daughter of |
. |
. |
| (Surname) |
(First Name) |
(Middle Name) |
presently residing at House Number Taluk District .
State (Pin Code) . . and having permanent residence at House No . Taluk District State . (Pin Code) . .
Hereby declare that I am in control, custody or possession of captive animal and/or its offspring bred in captivity/animal article/trophy/uncured trophy/derived from animal (strike out whichever is not applicable) specified in Schedule I or Part II of Schedule II of the Wild Life (Protection) Act, 1972 having following description:
| 1. |
Common name of the animal species |
: |
| 2. |
Zoological name (Mention sub-species, if any) |
: |
| 3. |
Description of the item |
: |
| 4. |
State the condition of the item (provide four colour photographs of size 8 6 covering front, left and right profiles and a full photograph) |
: |
| 5. |
Number of item |
: |
| 6. |
Method of procurement: Purchase/gift/inheritance/any other mode specify |
: |
| 7. |
Date of procurement |
: |
| 8. |
Name of person/institution from whom obtained |
: |
| 9. |
Address of person/institution referred to in (6) above |
: |
| 10. |
Size (in metres/cms) |
: |
| |
(i) Length |
: |
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(ii) Width |
: |
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(iii) Height |
: |
| 11. |
Weight (in Kgs/gms) |
: |
| 12. |
Any specific mark that can help in identification of the item |
: |
| 13. |
Mention the age and sex in case of live animals: |
: |
(ii) I hereby declare that the above referred captive animal/item has been kept, stored or maintained at the following address:
. .
. .
(iii) I hereby declare that the above referred captive animal/item was acquired by me through legal means but no declaration has been made by me under sub-section (1) or sub-section (4) of Section 40 of the Wild Life (Protection) Act, 1972.
(iv) I further declare that I have read and understood the provisions contained in Sections 40-A, 42 and 43 of the Wild Life (Protection) Act, 1972 and state that the above shall not be transferred to anyone by any mode except by way of inheritance.
(v) I hereby give my consent for fixing an identification mark to each item and transponder in case of captive animal and assure that the mark or transponder will not be erased, altered or damaged and in the event of any damage, alteration or change of the mark, I shall inform the competent authority within twenty four hours.
I do hereby declare that the information given above is true to the best of my knowledge and belief.
| Place: |
Signature of the person making the declaration |
| Date: |
(Name) |
Acknowledgement Slip
Receipt of the application filed by Shri/Smt/ . . presently residing at . . (Full address and Telephone Number) . . in the Office of the is hereby acknowledged.
Signature
OFFICE SEAL