DEC Region
County
Town:
Name:
Are you affiliated with a local not-for-profit wildlife rehabilitation organization or center? Name of organization or center:
Link for your website or website of your organization:
Email Address:
Phone
Alternate Phone
License:	Assistant Class 1 Class 2
	RVS Certified? Oil Spill Training? License to Collect and Possess?
Animals accepted:	Large Mammals Small Mammals Raccoons Skunks Bats Raptors Song Birds Waterfowl Game Birds Reptiles/Amphibians Non-Migratory Birds
Other information regarding animals you accept or special knowledge or skills you are willing to share
State License #
Federal Migratory Bird License #

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