SHOOTING FIELD TRIAL REPORT

Under Section 26-52-1 of the Regulations of Connecticut State Agencies (RCSA): This report must be filled out and submitted by the Agent of the Commissioner within 7 days after the trial date.

Submit this completed form to: Wildlife Division, Bureau of Natural Resources, Department of Energy & Environmental Protection, 79 Elm Street, Hartford, CT 06106.

1. Permit Number:       2. Date of Trial:      

3. Individual or organization sponsoring trial:      

4. Type of Trial: State Land Private Land

5. Location and Town:      

6. Species and total number of birds put out for the trial:

Species Total

           

           

           

Species of birds shot Total

           

           

           

7. Number of persons participating in trial:       8. Number of dogs participating in trial:      

9. Number of tags used:       10. Number of man- hours involved:      

11. Approximate number of spectators:      

12. Estimated overall cost of the trial (economic impact):

Meal $      Value of Dogs $      Prizes $     Room $      Value of birds/mammals $     Publicity $      Value of Equipment $     

79 Elm Street, Hartford, CT 06106-5127www.ct.gov/deep

Affirmative Action/Equal Opportunity Employer

DEEP-SHOOTING-REPORT-012 REV. 7/11/2014

I certify that this is a complete and accurate report and to the best of my knowledge all regulations and conditions under which the permit was issued were observed.

Agent of the Commissioner Date: