33-384LOA/Rev.
05-19
JK
I
certify
that
I
am
eligible
to
apply
for
a
limited
landowner
permit.
All
farm
and
ranch
land
listed
is
qualifying
property
owned
and/or
leased
by
me
or
a
member
of
my
immediate
household.
I,
as
the
qualified
applicant,
request
a
limited
landowner
permit
to
be
issued
to
me.
Signature
of
Qualified
Applicant:
Date:
I
certify
that
my
privilege
to
hunt,
fish
or
harvest
fur
is
NOT
currently
revoked
in
any
jurisdiction
(county,
state,
city,
federal
or
Canadian
province),
and
I
am
NOT
delinquent
on
any
child
support
payments.
NOTE:
Submitting
incomplete
information
will
result
in
the
return
of
your
application.
The
farm
or
ranch
land
listed
in
this
application
must
be
used
for
agricultural
purposes.
Check
the
box
below
that
best
certifies
your
qualifications
for
a
limited
landowner
permit:
I
qualify
as
the
owner/leaseholder
of
the
land
listed.
I
qualify
as
a
child.
I
qualify
as
the
spouse.
I
qualify
as
a
sibling
sharing
ownership.
FARM
AND
RANCH
L
AND
-
LEGAL
DESCRIPTION
(If
additional
room
is
needed,
an
attachment
form
is
available.
Photocopied
application
forms
are
acceptable.)
Antelope
Unit
(first
choice):
Antelope
Unit
(second
choice):
Residency
Resident
Nonresident
Owner Applicant
Owner
Name
Quarter
Section
Township
Range
County
Acres
Own
Lease
Corp.,
Part.,
Trust
John
Doe
W1/2NW1/4
16
28N
15E
Cather
80
X
Check
One
Box
for
Each
Parcel
Listed
Expiration
Date
3-digit
code
3-digit
card
verification
number
on
back
of
card
Credit
Card
Number
–
VISA,
MasterCard
or
Discover
