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
the
spouse
or
child
of
the
owner
or
leaseholder,
or
sibling
sharing
ownership,
of
the
land
listed.
FARM
AND
RANCH
LAND
-
LEGAL
DESCRIPTION
(If
additional
room
is
needed,
an
attachment
form
is
available)
***Photocopied
applications
are
acceptable.
I
certify
that
I
am
eligible
to
apply
for
a
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
landowner
permit
be
issued
to
me.
Signature
Qualified
Applicant:
Date:
E-mail
address
permit
notification:
☐
☐
I
certify
that
I
am
a
RESIDENT
of
the
State
of
Nebraska
as
defined
by
the
rules
and
regulations
of
the
Nebraska
Game
and
Parks
Commission.
☐
☐
I
certify
that
my
privilege
to
hunt,
fish
or
harvest
fur
is
NOT
currently
revoked
in
any
state,
and
I
am
NOT
delinquent
on
any
child
support
payments.
Yes
No
Quarter
Section
Township
Range
County
Acres
Own
Lease
W
1/2
NW1/4
16
28N
15E
Cather
80
X
Check
one
box
for
each
parcel
listed.
