Form Pr 2563 – Fill Out and Use This PDF

Instructions for Completing Game Bird Hunting Preserve Application and License Form

Applicants for new, renewal, or amended licenses must read and understand the Information Circular for Michigan Licensed Game Bird Hunting Preserves (IC 2563-1) before submitting this application. Incomplete or incorrectly completed applications will be returned unapproved. All attachments must be stapled to the completed application and must be 8 ½ inches by 11 inches in size (except for checks or money orders). Questions should be addressed to: PERMIT SPECIALIST, WILDLIFE DIVISION, MICHIGAN DEPARTMENT OF NATURAL RESOURCES (MDNR), PO BOX 30444, LANSING, MI 48909-7944, 517-373-9329, or TTY/TDD 711 (Michigan Relay Center).

FEE – The fee for this license is $105 for preserves 320 acres or less, or $180 for preserves more than 320 acres. Preserves shall not exceed 640 acres. Checks or money orders shall be made payable to the “State of Michigan.” If submitting more than one renewal application, attach a check or money order in the correct amount to each application. There is no fee for amended applications.

1.Applicant Information: All information must be typed or printed neatly.

2.Preserve Size and Location: Indicate the county, township, and section(s) of the proposed preserve property. If the proposed location encompasses two counties or townships, indicate both within the space provided. Acres owned plus acres leased must equal the total acres of the preserve. The total acres of preserve must match the required plat map outline and legal description. Preserves proposing the use of upland game bird species must be at least 80 acres and not greater than 640 acres. If there is more than one owner of leased (or rented) property, attach additional sheets. See “Acreage Requirements” on page 1 of IC 2563-1.

3.Preserve Information: Indicate if different than Applicant Information.

4.Preserve Classification: Indicate all that apply.

5.License Type: Indicate the license type and attach any required documents.

Applicants for a new license must attach: a) two copies of a township plat map with the proposed preserve boundary clearly outlined. Township plat maps are available from the Permit Specialist (517-373-9329); b) two copies of a complete legal description of the proposed preserve property; and c) the fee (see Fee above). See “Process for New Applications” starting on page 5 of IC 2563-1.

Applicants for a renewal license must complete the application in its entirety, including the license number in the appropriate area (to the right of applicant’s signature and date). Attach the fee (see Fee above). Do not attach plat maps or legal descriptions. Licenses will be renewed for the same property as previously approved. Do not propose changes to preserve property when renewing a license. This requires a separate amended application. See “Process for Renewing Licenses,” starting on page 7 of IC 2563-1.

Applicants for an amended license must complete the application in its entirety, including the license number in the appropriate area (to the right of applicant’s signature and date). Attach an explanation of the proposed changes. Do not attach plat maps or legal descriptions, unless proposing a change to the preserve property. Amended applications proposing changes to preserve property will not be accepted during the months of April, May, or June of the year a license expires. There is no fee to amend a license. See “Process for Amending Licenses” starting on page 8 of IC 2563-1.

6.Species and Number of Birds for Release: Indicate the species proposed for use and estimate the number of birds of each species that will be released during each season covered by the license. Do not indicate the total birds to be released for the (three-year) duration of the license. The approved license authorizes the use of only those species indicated.

7.Applicant/Licensee Signature: Sign and date the application. If renewing or amending a license, include the license number. Licensees must abide by all regulations and requirements stated on this form and IC 2563-1. Licensed preserve property and records are subject to inspection by a Conservation Officer or other designated representative of the Department at any reasonable time. Such inspections may include an evaluation of: disposition of boundary signs, accuracy of records, and minimum specifications and amenities for holding facilities. Refer to IC 2563-1 for more information regarding these requirements. Licensees not in compliance with regulations and requirements may be subject to license revocation, fine, and/or imprisonment. Furthermore, Licensees agree to the following:

LIABILITY. Licensee hereby releases, waives, discharges and covenants not to sue the State of Michigan, its departments, officers, employees and agents, from any and all liability to Licensee, its officers, employees and agents, for all losses, injury, death or damage, and any claims or demands thereto, on account of injury to person or property, or resulting in death of Licensee, its officers, employees or agents, in reference to the activities authorized by this License.

INDEMNIFICATION. Licensee hereby covenants and agrees to indemnify and save harmless, the State of Michigan, its departments, officers, employees and agents, from any and all claims and demands, for all loss, injury, death or damage, that any person or entity may have or make, in any manner, arising out of any occurrence related to (1) issuance of this License; (2) the activities authorized by this License; and (3) the use or occupancy of the premises which are the subject of this License by the Licensee, its employees, contractors, or its authorized representatives.

8.Mail Applications: Staple all required attachments to the completed application; and mail to the address indicated.