Junior Duck Stamp Program Conservation and Design Contes

Junior Duck Stamp Program Conservation and Design Contest Entry Form

OMB Control No. 1018-0172
Expiration Date xx/xx/xxxx

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

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

Grades K-3

Grades4-6

Grades 7-9

Grades 10-12

_________________________________________________________________________________________________________________
Grade
First Name
Last Name
Age
________________________________________________________________________________________________________________
Home/Residence Mailing Address
(Street or P.O. Box)
________________________________________________________________________________________________________
City
State
Zip Code
___________________________________________________ (_______) _________________________________________________
Parent Name
Parent Phone
Parent Email
Does student have a Social Security Number? Yes/No
VISA Immigration Number? Yes/No
Is student a Foreign Exchange Student? Yes/No

Entry Information

________________________________________________________________________________________________________________
Title
Species of bird (from permitted species list)
________________________________________________________________________________________________________________
Medium and Style Used (e.g., acrylic, colored pencil, realistic, abstract, ethnic, pop, etc.)

Conservation Message

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.
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________

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

First Name

Last Name

__________________________________________________________________________________________________________

School / Studio / Organization / Troop Name

Daytime Phone

__________________________________________________________________________________________________________

Mailing Address

City State Zip

__________________________________________________________________________________________________________

Email Address
Please check one of the following:

 Parent  Teacher  Counselor  Troop Leader  Other

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

 Read the Annual Contest Brochure.

For Office Use
Only

 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.

 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.

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

states have special due
dates: CA, MD and SD - Feb 1; MA - Feb 15; ME, MO, NV,OH, OK, RI, UT, VA, WV Mar 1. All other states, territories and D.C. postmark by March 15.
If you have questions please contact your state coordinator.
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. 1018-0172. We estimate public reporting for this collection of information to average 20
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: PRB (JAO/3W), Falls Church, VA 22041-3803, or via email at [email protected]. Please do not
send your completed form to this address.

AUTHENTICITY AND LIABILITY STATEMENT
Do not copy the work of others. Plagiarism is serious. Students, parents, and
teachers do not sign this entry form without reading the following statement
and referring to the Annual Contest Brochure:
I have read and understand the rules on submitting unique artwork and hereby
certify that this is my original work and not copied or traced from published
photos, magazines, books, illustrations, other 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.
Signature of Student _______________________________________ Date _______________
Signature of
Supervising Parent ________________________________________ Date _______________
Signature of
Supervising Teacher _______________________________________ Date _______________

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