Junior Duck Stamp Program Conservation and Design Contes

Grades4-6

Grades 7-9

Grades 10-12

Last Name

Daytime Phone

City State Zip

 Parent  Teacher  Counselor  Troop Leader  Other

Signature of
Supervising Teacher _______________________________________ Date _______________

Signature of
Supervising Parent ________________________________________ Date _______________

Signature of Student _______________________________________ Date _______________

DO NOT COPY THE WORK OF OTHERS. PLAGIARISM IS SERIOUS!
STUDENTS, PARENTS, AND TEACHERS, DO NOT SIGN ENTRY FORM
WITHOUT READING THE FOLLOWING STATEMENT:
I hereby certify that this is my original work and not copied or traced from
published photos, magazines, books, illustrations, artists’ published works
or other materials protected by copyright laws. I understand that the U.S.
Fish and Wildlife Service and other sponsors are not responsible for loss or
damage to my artwork. I grant exclusive rights to the U.S. Fish and Wildlife
Service and its designees to use, alter, copy, publish, and display my artwork
for reproduction and promotional purposes as they see fit without
compensation to me, including the use of my photograph if taken at a related
Junior Duck Stamp program function or submitted to a state or national
coordinator. I further understand that the U.S. Fish and Wildlife Service has
the exclusive right to disqualify any entry whose authenticity is questionable.

AUTHENTICITY AND LIABILITY STATEMENT

In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), the U.S. Fish and Wildlife Service collects
information necessary to consider your submission for the Junior Duck Stamp Contest. Information requested in
this form is purely voluntary. Failure to provide all requested information may be sufficient cause for the U.S.
Fish and Wildlife Service to reject your submission. According to the Paperwork Reduction Act of 1995, 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. OMB has approved this collection of information and assigned
Control No. 1018-####. We estimate public reporting for this collection of information to average 5 minutes,
including time for reviewing instructions, gathering and maintaining data and completing and reviewing the form.
Direct comments regarding the burden estimate or any other aspect of the form to the Service Information
Clearance Officer, Fish and Wildlife Service, U.S. Department of the Interior, 5275 Leesburg Pike, MS: BPHC,
Falls Church, VA 22041-3803, or via email at [email protected]. Please do not send your completed form to
this address.

If you have questions please contact your state coordinator.

states have special due
dates: SC - Jan 10; MD - Feb 1; MA and NJ - Feb 15; MO, OH, RI and VA -Mar 1. All
other states, territories and D.C. postmark by March 15.

 Confirm the address of your STATE RECEIVING SITE.
 Postmark Entries by your State Deadline. The following

 Check contact phone numbers for accuracy.
 Have student, parent, and supervising adult sign the Entry Form.
 Affix the Entry Form to the back of the entry.
 Include a completed Reference Form.

 Prepare entry as a horizontal design on 9”x 12” media no more than 1/4" thick.
 Fill out the Entry Form completely with all required information.

 Read the contest brochure.

For Office Use
Only

Spanish version of this entry form online at http://www.fws.gov/migratorybirds/pdf/Education/junior-duck-stamp-conservation-program/Spanish%20Forms%20Entry.pdf
Para una version espanola de esta forma http://www.fws.gov/migratorybirds/pdf/Education/junior-duck-stamp-conservation-program/Spanish%20Forms%20Entry.pdf

Supervising Adult: Fill in the STATE RECEIVING SITE address here (before duplicating)
Participants: Mail your art to this address.

Email Address
Please check one of the following:

__________________________________________________________________________________________________________

Mailing Address

__________________________________________________________________________________________________________

School / Studio / Organization / Troop Name

__________________________________________________________________________________________________________

First Name

__________________________________________________________________________________________________________

Supervising Adult / Teacher: Please fill in the following information (Print Clearly)

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Write a message explaining what you have learned about wetland conservation and the importance of
conserving habitat for wildlife, or why conservation is important to you. Sample messages on website.

Conservation Message

_________________________________________________________________________________________________________________
Medium Used (i.e. acrylic, colored pencil)

_________________________________________________________________________________________________________________
Title
Species of bird (from permitted species list)

Entry Information

Does student have a Social Security or VISA Immigration Number? Yes/No
Is student a Foreign Exchange Student? Yes/No

___________________________________________________ (_______) _________________________ (_______)_________________
Parent Name
Parent Daytime Phone
and
Cell Phone

________________________________________________________________________________________________________________
Home/Residence Mailing Address
(Street or P.O. Box)
Email
Address
_________________________________________________________________________________________________________________
City
State
Zip Code

_________________________________________________________________________________________________________________
First Name
Last Name
Age

Student Information Please print clearly

Grades K-3

Group (Check One) Group I  Group II  Group III  Group IV  Before Mailing Please Remember to:

http://www.fws.gov//birds/education/junior-duck-stamp-conservation-program.php

Junior Duck Stamp Program Conservation and Design Contest Entry Form

OMB Control No. 1018-####
Expiration Date ##/##/####