Form 3-2405 Visitor Check-In Permit and Use Report

OMB Control No. 1018-0153

Self-Clearing Check-In Permit

Expires XX/XX/XXXX

You must complete the Check-In portion of this daily permit and put it in
the permit box before engaging in any activity on the Refuge.

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U. S. Fish and Wildlife Service
Tensas River National Wildlife Refuge
Each user must carry the Daily Visitor Registration portion while on the Refuge.
At the conclusion of your visit, complete the following information and put this
portion in the permit box.
Number of hours spent on Refuge: ________
Hunter Harvest Information:
Did you harvest any wildlife?
Yes
No
How many? ______________________________________________________
(Example: Squirrel-3, Deer-1)

Game Species

Squirrel

Rabbit
Buck

Deer Bagged:

Raccoon
Doe

Woodcock

Waterfowl

# of Points _________

Turkey Harvested : Weight:______________________________
Spur Length: R ________ L ________ Beard Length: _________________
Incidental Species

Beaver
Method:

Coyote
Gun

Crossbow

Hog

Other (Please Specify)____________

Primitive Firearm

Bow

Muzzleloader

Angler Harvest information: ______________________________________
Number of Fish Caught ______________ Type _______________________
Did You Observe:

Black Bear

Hog

--- Notice --In accordance with the Privacy Act (5 U.S. C. 552a) and the Paperwork Reduction Act
(44 U.S. C. 3501), please note the following information: 1. The issuance of a permit
and collection of fees on lands of the National Wildlife Refuge System is authorized by
the National Wildlife Refuge System Administration Act (16 U.S. C. 668dd-ee) as
amended, and the Refuge Recreation Act (16 U.S. C. 460k-460k-4). 2. This information
is required in order to obtain or retain a benefit. We collect this information to evaluate
the qualifications, determine eligibility, and document permit applicants under the above
Acts. It is our policy not to use your name for any other purpose. The information is
maintained in accordance with the Privacy Act System of Records: National Wildlife
Refuge Special Use Permits--Interior, FWS-5. All information you provide will be
considered in reviewing this application. False, fictitious, or fraudulent statements or
representations made in the application may be grounds for revocation of the permit and
punishable by fine or imprisonment (18 U.S.C. 1001). Failure to provide all required
information is sufficient cause for the U.S. Fish and Wildlife Service to deny a permit. 3.
We estimate the public reporting burden on the applicant for information collection to be
5 minutes. This burden estimate includes time for reviewing instructions, gathering and
maintaining data and completing and reviewing the form. You may direct comments
regarding the burden estimate or any other aspect of the form to the Service
Information Clearance Officer, U.S. Fish and Wildlife Service, Mail Stop BPHC, U.S.
Department of the Interior, 1849 C Street, NW, Washington D.C. 20240. 4. Routine use
disclosures may be made: (a)to the U.S. Department of Justice when related to
litigation or anticipated litigation; (b) of information indicating a violation or potential
violation of a statute, rule, order, or license to appropriate Federal, State, local or
foreign agencies responsible for investigating or prosecuting the violation or for
enforcing or implementing the statute, rule, regulations, order, or license; (c) from the
record of the individual in response to an inquiry from a Congressional office made at
the request of the individual (42 FR 19083; April 11, 1977); and (d) to provide
addresses obtained from the Internal Revenue Service to debt collection agencies for
purposes of locating a debtor to collect or compromise a Federal Claim against the
debtor, or to consumer reporting agencies to prepare a commercial credit report for use
by the Department (48 FR 54716; December 6, 1983). 5. An agency may not conduct
or sponsor and a person is not required to respond to a collection of information unless
it displays a currently valid OMB control number.

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Self-Clearing Daily Vehicle Permit
Each user must enter the date and, while on the Refuge,
display this tag in the vehicle in clear view.

VEHICLE TAG
Other Side Face-up
FWS Form 3-2405
10/15

U. S. Fish and Wildlife Service
Tensas River National Wildlife Refuge
Self-Clearing Check-In Permit
Daily Permit
Check in Date:__________(pre-coded) Permit #_________Name:
Telephone #:
(fold and tear here)
Self-Clearing Daily Visitor Registration Permit
Daily Permit
Date _________________(pre-coded) Permit #__________________
Daily Visitor Registration portion must be carried by each user while
on the Refuge. This hunt report must be completed and put in permit
box at the conclusion of the holder’s activity within the Refuge.
Name_______________________________Date________________
City ____________________________State____________________
Zip Code_________________________________________________
Purpose of Visit: (Please check all that apply)

qHunting qBirding qWildlife Observation
qPhotography qAuto Touring qFishing qHiking
qBoating/Canoeing qVisitor Center qSpecial Event
qEnvironmental Education Class qVolunteering
qOther Recreation (please specify):__________________
________________________________________________
________________________________________________
Tensas River National Wildlife Refuge
Indicate the numbered area visited

Tensas River

National Wildlife Refuge
Waverly Exit

To
Delh
i

80

20

Tallulah
Exit

2

577

Spur
577

P

1

7

P

Tensas
River

6

P

4
Big
Lake
WMA

P

5

884

3 6
575
888

888

P

P

4
0

65

N

Legend
Refuge Boundary
ATV Trail
Manned Check Station
Self Check Station
Refuge Headquarters
Inholdings

8,000 16,000 24,000 32,000 Feet

(fold and tear here)

Date

Self-Clearing Vehicle Permit Daily Permit
(pre-coded) Permit #

While on the Refuge, each user’s vehicle tag must be dated and
displayed in clear view on the vehicle used to enter the Refuge.