REQUEST FOR RAZOR CLAM PERMIT FOR

August 22, 29 and 30, 2006

(Required for the harvesting of razor clams in certain restricted areas)

PLEASE COMPLETE THE FOLLOWING:

License Number _______________________  License Type: (Circle one)   CLM    TFL

Name_______________________________________________________________________

Address_____________________________________________________________________

City/State/Zip___________________________________________________________

• This permit will apply only to the designated area of the Wye River

I UNDERSTAND THAT, making a false statement on this form is punishable by law (Cr, 8-606.)

Signature (Required)___________________________________________________

Telephone (Daytime)_______________________ (Evening)_________________________