2017 LANDOWNER (GRATIS)MOOSE LICENSE APPLICATIONNorth Dakota Game and Fish DepartmentLicensing Division, SFN 6346

Deadline for mailing application is March 22, 2017.Please note that some post offices use the following days postmark if mailed after regular hours. Mail your application early to ensure a proper postmark.

SEASON DATES: Units M6, M8, M9, M10, M11 Bow Season (legal archery equipment only) — September 1 through September 24. UnitsM6,M8,M9,M10,M11RegularSeason(legalarcheryequipmentorfirearms)–October13throughNovember5. INSTRUCTIONS (If you need any assistance in filling out this application, contact the N.D. Game & Fish Department).

1. Onlypersonswhoown,orleaseforagriculturalpurposesandactivelyfarmorranch,aminimumof150acresof land in the units listed at right are eligible to apply for one of the landowner moose licenses (see transfer of eligibility at bottom of form). Licenses shall be issued by a lottery procedure amongst all eligible landowner licenseapplicants.Thelandownermooselicenseisvalidonlyuponlanddescribedontheapplicationbelow.The licensee may not hunt the entire unit. The licensee is able to hunt during both the regular season and bowseason(legalarcheryequipmentonlyduringbowseason).Thelandownermooselicenseisvalidforanyanimal, regardless of sex or age.

2. OnlyONEapplicationwillbeacceptedforeachindividual.Thereisnoprovisiontoapplyasaparty.

3. Filloutallrequiredinformationinthesectionsbelow.Signanddateapplication.Ifanypartoftheapplicationisincompleteorinerror,theapplicationwillnotbeprocessedandwillbereturnedtosender.IfyouarenotaUScitizen,youmustapplyonline.

4. Ifaperson(nottransferee)isunsuccessfulinharvestingamoose,thatpersonmayreturntheunusedlicensetotheDepartmentandapplyfor,butnottransfer,anadditionallicensetohuntmooseinfutureyears.Ifapersonreceivesanadditionallicense,theperson’sspouse,childrenandparentslivingwiththepersonarenoteligibletoreceivealicensefortheunitinwhichthelandislocated,unlessthepersonsellsortransferstheland.ApersonwhoreceivesanadditionallicenseisnoteligibletoparticipateintheRockyMountainElkFoundation/GameWardenMuseumraffle.

MAIL TO:Moose Lottery – NDGFD

100 N. Bismarck ExpresswayBismarck, ND 58501-5095

Phone (701) 328-6300

AS LANDOWNER OR LESSEE, I CERTIFY THAT: (Persons making false statements on this form may be subject to prosecution.)

•Iwillbeatleast14yearsofageonorbeforeDecember31ofthisyear;•Thelanddescribedabovetotals150acresormore;•IhaveactuallylivedinthestateofNorthDakotaormaintainedmyresidence thereinforthepastsixmonths(residencywaiversarenoteligible);

•Alltheabovedescribedlandiseligibleforalandownermooselicense(LeasedStateorFederalGovernmentlandisnoteligible);•IhaveneverreceivedalicensetohuntmooseinNorthDakotathruthelottery(exception,see#4above);•Thisistheonlyapplicationbeingmadeinmynamefora2017mooselicense;•Iamsubmittingtheoneandonlyonelandownermooselicenseapplicationforlanddescribedabove;•IfIreceivealandownermooselicenseIamnoteligibletoapplyforalicensetohuntmooseinfutureyears(exception,see#4above).

CHECK BOX BELOW IF IT APPLIES TO YOUR SITUATION:

I transfermyeligibility fora landowner license tomyspouseor legaldependentwho resideswithme. Iunderstand thatbydoing this Igiveupmyeligibilitytoapplyforalicensetohuntmooseinfutureyears.IalsounderstandthatImaynottransferalicensereceivedasaresultofbeing unsuccessfulinharvestingamooseduringapreviousyear(see#4above).

As an applicant I certify that I am eligible for a landowner moose license. Applicant must sign below ONLY if they are not the landowner or lessee. Regardless of who uses the license, the landowner or lessee must sign to the right.

_______________________________________________________________________________APPLICANT’SSIGNATURE(IFNOTLANDOWNERORLESSEE) DATESIGNED

Ifnototherwisespecifiedinanagriculturallease,thelandownerisentitledtoreceivethelandownermooselicense.

Please list unit where land is located

APPLICANTINFORMATION:Printoneletterornumberperbox,leaveoneblankboxasspacebetweenwords.

CITY STATE ZIP

LASTNAME FIRST MIDDLE SOCIAL SECURITY NUMBER (required) SEX

MAILINGADDRESS

INFORMATION IN THIS SECTION SHOULD BE COMPLETED BY LANDOWNER OR LESSEENOLESSTHAN150ACRESOFLANDMUSTBEOWNED,ORLEASEDFORAGRICULTURALPURPOSES

ANDACTIVELYFARMEDORRANCHED,TOBEELIGIBLEFORLANDOWNERLICENSE.LEGAL LAND DESCRIPTION. PLEASE LIST BELOW. (Note: For additional land descriptions - attach separate sheet.)

Iownallthelanddescribedasfollows(Mustprovidefulllegaldescriptionifownershipislessthanafullsection.):________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

or I lease, for agricultural purposes and actively farm or ranchall thedescribed landfromthefollowingprivateparty(ies)who is(are)not applying for the landowner license. You must list owner(s) of leased land on the following lines or application will be returned to you! Proof of lease to be supplied on request.

Legalleasedlandisdescribedasfollows(Mustprovidefulllegaldescriptionifownershipislessthanafullsection.):________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

__________________________________ ________________ PRINTEDNAMEOFLANDOWNERORLESSEE DATEOFBIRTH

___________________________________________________SIGNATUREOFLANDOWNERORLESSEE

___________________________________________________DATESIGNED

Total AcreageApplied For:

_____________

PHONE IF AGE 18 or OLDER - N.D. DRIVER’S LIC# or N.D. NONDRIVER PHOTO ID# (Required)

BIRTHDATE(mo.) (day) (yr.) AGE

Owner of Leased Land

Owner of Leased Land

Landowner Licenses availableformoose(Seemaponback)

Unit Number Available M6 1 M8 2 M9 12 M10 12 M11 8

Section Township Range County

Section Township Range County

Section Township Range County

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Legal Land Description

Legal Land Description

Section Township Range County

Section Township Range County

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Units Where Landowner Licenses Are Available For Moose:

Unit M6 (1 license) - Those portions of Barnes, Benson, Burleigh, Cass, Dickey, Eddy, Emmons, Foster, Grand Forks, Griggs, Kidder, LaMoure, Logan, McIntosh, McLean, Nelson, Ramsey, Ransom, Richland, Sargent, Sheridan, Steele, Stutsman, Traill and Wells counties bordered on the east by Minnesota, on the south by South Dakota, on the west by the Missouri River, and on the north by Units M5 and M9 (or described as a line starting at the intersection of US Highway 83 and ND No. 200A near Washburn, then north on ND No. 200A, then east on ND No. 200, then north on US Highway 281, then east on US Highway 2 to the Minnesota line.).

Unit M8 (2 licenses) - Those portions of Bottineau, Cavalier, Pierce, Ramsey, Rolette and Towner counties bordered on the east by ND No. 1, on the north by Canada and Unit M4, on the west by ND No. 60, and on the south by ND No. 17.

Unit M9 (12 licenses) - Those portions of Benson, Bottineau, McHenry, McLean, Towner, Pierce, Ramsey, Renville, Sheridan, Ward and Wells counties bordered on the east by ND No. 1 and Unit M6, and on the north by Unit M8, Unit M4, and Canada. The western and southern borders are composed of ND No. 256 and US Highway 83 to the point where the highway crosses the southern portion of Lake Sakakawea, then west along Lake Sakakawea and south along the Missouri River to Washburn, then north on ND No. 200A, then east on ND No. 200 to the junction of US Highway 281 at Carrington. Mallard Island is included within this unit.

Unit M10 (12 licenses) - Divide and Burke counties and those portions of Bottineau, Mountrail, Renville, Ward and Williams counties bordered on the east by Unit M9, on the north by Canada, on the west by Montana, and on the south by US Highway 2.

Unit M11 (8 licenses) - Those portions of Dunn, McKenzie, Mercer, McLean, Mountrail, Ward and Williams counties bordered on the east by Unit M9, on the north by US Highway 2, and on the west by Montana. The southern border starts at the junction of Montana and ND No. 200, then east along ND No. 200 to US Highway 85, then south along US Highway 85 to ND No. 200, then east along ND No. 200 to the Missouri River east of Pick City (Unit M9).

SOCIAL SECURITY NUMBER REQUIREMENT. Inaccordancewithstate lawNDCC20.1-03-35and42USCode666(a) (13)and(16), theDepartment isrequiredtocollectsocialsecuritynumbersfromallpersonsobtaininghunting,fishing,orotherrecreationaltypelicenses.Yoursocialsecuritynumberservesasyourprincipalidentificationnumberto determinelicenseeligibility.Itiskeptconfidential,howeveritmaybeprovidedtolawenforcementagenciesandtheStateDisbursementUnittoenforcechildsupportobligations.

TheNDGFDreceivesfederalfinancialassistancefromtheUSFishandWildlifeService.InaccordancewithTitleVIoftheCivilRightsActof1964,Section504oftheRehabilitationActof1973,TitleIIoftheAmericanswithDisabilitiesActof1990,theAgeDiscriminationActof1975,andTitleIXoftheEducationAmendmentsof1972,theNDGFDjoinstheUSDepartmentoftheInterioranditsBureausinprohibitingdiscriminationonthebasisofrace,color,nationalorigin,age,disability,sex(ineducationprogramsoractivities)andalsoreligionfortheNDGFD.Ifyoubelieveyouhavebeendiscriminatedagainstinanyprogram,activity,orfacilityasdescribedabove,oryoudesirefurtherinformation,pleasewriteto:NDGameandFishDepartment,Attn:ChiefAdministrativeServices,100N.BismarckExpressway,Bismarck,ND58501-5095orto:USFishandWildlifeService,Attn:CivilRightsCoordinator,4401N.FairfaxDrive,MailStop:MBSP-4020,Arlington,Virginia22203.If you are disabled and desire application information for hunting and fishing opportunities in this state please contact the Department at 701-328-6300.TheTTY/TTD(RelayND)numberforthehearingorspeechimpairedis1-800-366-6888.

You can also apply for your landowner moose license via the internet — 24 hours a day — 7 days a week,making sure your application is in before the deadline. Visa, Discover and MasterCard accepted.

APPLYING BY COMPUTER . . . . QUICK – CONVENIENT – EASY visit our website at gf.nd.gov

Regular application feesapply with no service charge added.

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In accordance with state law (NDCC 20.1-02-05), a resident who is 18 years of age or older must submit a ND drivers license number or a ND nondriver photo ID number when applying for a license.