STATE OF MARYLAND Department of Natural Resources FISHERIES SERVICE

REQUEST FOR A PROVISIONAL CHARTERBOAT PERMIT

The Provisional Charterboat permit is not transferable and is valid only to an authorized person operating a vessel for charter fishing trips originating from the tidal waters of Virginia.

To apply you must submit: an application, proof that you were a VA charterboat licensee in 2001 and 2002 and a copy of your current coast guard license and current Virginia chaterboat license.

PLEASE COMPLETE THE FOLLOWING:

2001 Virginia License Number __________________ 2002 Virginia License Number _____________________

Name______________________________________________________________________


Address_____________________________________________________________________


City/State/Zip_________________________________________________________________


I certify UNDER PENALTY OF PERJURY that I am currently licensed by the Virginia Marine Resources Commission to operate a charterboat in its jurisdictional tidal waters and was active as a charterboat captain in 2001 and 2002 and that ALL information provided in this form is true, complete and correct to the best of my knowledge and belief. I UNDERSTAND THAT, I will be required to report fishing activity covered by the permit to the Maryland Department of Natural Resources. I ALSO UNDERSTAND THAT,making a false statement on this form is punishable by law (CR. 8-606).

Signature (REQUIRED)__________________________________________________________

Telephone (Daytime)_______________________ (Evening)__________________________

When you have completed the form you may do one of the following:

(1) Mail to: MD. Department of Natural Resources Tawes State Office Bldg. B-2 Attn: Belinda Gray 580 Taylor Ave. Annapolis, MD 21401 or

(2) Fax in care of Belinda Gray to (410) 260-8279

Please allow at least one week to process your application.

If you have any problems with printing this form or if you have questions, please email Belinda Gray at bgray@dnr.state.md.us