Application For A Replacement Carcass Tag
41-19-8 (11/05)-7~
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NEW YORK STATE DEPARTMENT OF ENVIRONMENTAl CONSERVATION
APPLI CAT I ON FOR A REPLACEMENT
CARCASS TAG
PRINT - Name (First. ML last)
Date of Birth:
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Address:
Customer I D Number:
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Customer 10 No. is
located on License/
Privilege Panel
under bar code.
(Not Document
No.)
You MUST furnish the full 12-digit ID number that appears
on your original license.
Check type of residence:
Check Type of License: .
o Big/ Small Game 0 Sportsman
o Hunting (Small Game Only) 0 Super Sportsman
Check Item - Desired
o Back Tag - No Fee 0 Deer Carcass/ Report - $10.00
o Bear Carcass/ Report - $10.00
Specific circumstances under which the carcass tag was lost or destroyed:
o Resident
o Non-Resident
o Non-Res Big Game
o Legacy
o Muzzle
o Turkey
o Bow
o Turkey Carcass/Report - $10.00
I hereby report that I lost or accidently destroyed the carcass tag/permit portion of the above license. I request that the department
issue a replacement tag/permit. I hereby affirm. under penalty of perjury and other appropriate provisions of the law. that no deer.
bear or turkey was taken pursuant to this license. I further affirm that the carcass tag/permit was lost or destroyed as reported in this
application. If the ORIGINAL carcass tag/permit is found or recovered. I understand that I must surrender it immediately to the License
Issuing Agent which issued the duplicate.
I UNDERSTAND THAT GRATUITOUSLY REPORTING TO'A PUBLIC OFFICIAL OR AGENCY THE ALLEGED
OCCURRENCE OF AN INCIDENT, WHICH DID NOT IN FACT OCCUR, CONSTITUTES A CRIME PURSUANT TO THE
PENAL LAW. IN ADDITION, MAKING A FALSE STATEMENT IN APPLYING FOR A LICENSE, STAMP, OR PERMIT
UNDER THE ENVIRONMENTAL CONSERVATION LAw, OR FOR A CERTIFICATE IN LIEU OF A lOST OR
DESTROYED LICENSE, STAMP OR A DUPLICATE BIG GAME LICENSE TAG IS A MISDEMEANOR.
FOR ISSUING AGENT USE ONLY
Duplicate Issued By:
Agent:
ACldress:
CERTIFICATION: I hereby affirm under penalty of perjury that all theinformatiun provided on
this form is true to the best of my knowledge and belief. and that I am not applying for a
Replacement Carcass Tag for which my privileges are suspended or revoked. False statements
are punishable as a Class A misdemeanor pursuantto Section 210.45 of the Penal Law.
Phone Number: <--J
By:
Date:
Time:
Replacement Document(s) Number:
Signature of Applicant
Date
LtO:Reviews application for completeness and issues duplicate tag.
LtO must enter the original 12-digit Customer ID Number on the
replacement tag.
ISSUING AGENT MUST RETAIN THIS OR!GINAL SIGNED DOCUMENT ON FILE AND AVAILABLE FOR REVIEW
AT THE REQUEST OF THE DEPARTMENT FOR THREE YEARS.
,/