W. Va. Code R. agency 58, tit. 58, ser. 58-17, app A
RESIDENT COUNTY OR STATEWIDE
FUR DEALER'S APPLICATION FORM
WEST VIRGINIA DIVISION OF NATURAL RESOURCES
APPLICATION FOR A RESIDENT FUR DEALER'S LICENSE
(West Virginia Code '20-2-49)
INITIAL APPLICATION (___) RENEWAL APPLICATION (___)
CHECK ONE:
(___) Resident County License for the Counties of:
_______________________________________________
(___) Resident Statewide License
NAME: __________________________________________________
STREET or BOX: __________________________________________
CITY and COUNTY: ________________________________________
STATE and ZIP CODE: _____________________________________
TELEPHONE NUMBER: ____________________________________
CURRENT LICENSE NUMBER: ______________________________
I certify that I have been a domiciled resident of the state of West Virginia for a period of at least six (6) months prior to the date of this application. I agree to abide by the terms and conditions of my license.
_____________________________ ______________
(Signature of Applicant) (Date)
| Annual Fee for Resident County License: $1.00 per county Annual Fee for Resident Statewide License: $10.00 Law Enforcement Section Annual Fee for Agent's Permit: $2.50 for each agent | RETURN TO: WV Division of Natural Resources Law Enforcement Section Room 837, Building 3 State Capitol Complex Charleston, WV. 25305 |
THE FOLLOWING AGENTS ARE EMPLOYED BY THE APPLICANT:
_____________________________________________________________
Name of Agent (Street or Box)
_____________________________________________________________
(City) (County) (State) (Zip Code)
I agree to abide by the terms and conditions of my permit.
_________________________ _____________
(Signature of Agent) (Date)
-------------------------------------------------------------------------------------------------------------------
__________________________________________________________
(Name of Agent) (Street or Box)
_______________________________________________________________
(City) (County) (State) (Zip Code)
I agree to abide by the terms and conditions of my permit.
_________________________ _____________
(Signature of Agent) (Date)
-------------------------------------------------------------------------------------------------------------------
___________________________________________________________
(Name of Agent) (Street or Box)
_____________________________________________________________
(City) (County) (State) (Zip Code)
I agree to abide by the terms and conditions of my permit.
_________________________ ______________
(Signature of Agent) (Date)
___________________________________________________________
(Name of Agent) (Street or Box)
_____________________________________________________________
(City) (County) (State) (Zip Code)
I agree to abide by the terms and conditions of my permit.
_________________________ _____________
(Signature of Agent) (Date)
W. Va. Code R. agency 58, tit. 58, ser. 58-17, app A