GP generic consent form rev 2010

Office use only: US FWS Registration #_______________ Community assigned ID # _____________
GeesePeace Program Registration and Authorization
2015
.
I, _________________________________________________________, do hereby attest that I am the owner or authorized
agent for the property(s) listed below and on the reverse side.  Check if locations are listed on reverse side.
Town ___; Village ___; City ____; Borough of ____; Name __________________________________________
•
Or
•
Common grounds of
Civic Association/Home Owners Association/Subdivision ______________________________________________
Or
•
Or
•
Park___; School ___; Golf Club ___; Other Recreational __; Name: ____________________________________
Private Residential/Commercial property ___; Other Private _____ Name _________________________________
Street Address or
Property Location Description/Name
County or
Equivalent
City/Town
State
Contact information
Mailing Address: Name: ___________________________________________________
Street: _____________________________________________________
City: ______________________________________ State: ____ ZIP _________
Phone: ______________________ E-mail: ______________________ Fax: ______________________
Registration with US Fish and Wildlife Service
I authorize my local government or agency, thereof, _____________________________________________________
to register, carryout and report this activity for me in accordance with the US FWS Regulation Title 50: Wildlife and
Fisheries, PART 21 – MIGRATORY BIRD PERMITS; SUBPART D. “Depredation order for resident Canada geese
nests and eggs.”
Or I registered with the US FWS authorizing ________________________________________________ as our agent.
Authorization
I will allow staff of my local government or property owners association or program participants with GeesePeace
identification badges to oil/replace eggs or destroy nests on my property and provide access to this property for this
purpose. I understand this is a no fee service and is subject to availability of resources.
I understand that this activity may involve several visits to each site to identify nests, monitor egg production and to carry
out egg-oiling/replacement or nest destruction activities. I understand that some nests may not be found and some eggs
may be too developed to treat. I further understand that all personnel oiling eggs shall have in their possession this signed
access and authorization form, GeesePeace program identification and the US Fish and Wildlife Service registration form.
Hold Harmless
•
•
I understand that all participants in the GeesePeace program shall hold property owners and agents harmless for
all damage to person or property that results, in relation to this activity, whether through negligence, act of God, or
other cause.
I agree to hold harmless, GeesePeace and its agents or volunteers, GeesePeace partner organizations and the
local coordinating body or governmental jurisdiction for any damage to person or property that results, in relation
to this activity, whether through negligence, act of God or other cause.
No Feeding of Canada Geese Policy
I understand a “no feeding” of Canada geese policy must be in effect on the property at all times.
(Signature) ________________________________ Title _________________________________ Date: _________
Please return this signed form to your local Community coordinator:
Revision 2015-1
Office use only: US FWS Registration #_______________ Community assigned ID # _____________
Location of Properties for Registration (continued)
Street address or
Location Description/Name
County or
Equivalent
City/Town
State