AH-CD-601.docx 05/18 Wisconsin Department of Agriculture, Trade and Consumer Protection PO Box 93178, Milwaukee, WI 53293-0178 Phone: (608) 224-4872 Fax (608) 224-4871 FARM-RAISED DEER CWD TEST SAMPLE COLLECTOR APPLICATION For Owners and Eligible Representatives - For period ending June 30, 2023 s. ATCP 10.52(4), Wis. Admin. Code APPLICANT NAME APPLICANT COUNTY RELATIONSHIP TO FRDK LEGAL ENTITY APPLICANT MAILING ADDRESS STREET CITY STATE ZIP APPLICANT TELEPHONE #: APPLICANT CELL PHONE # APPLICANT E-MAIL ( ) - ( ) - APPLICANT SIGNATURE: FARM-RAISED DEER KEEPER INFORMATION LEGAL ENTITY ON FRDK REGISTRATION DOING BUSINESS AS (If different) FRDK MAILING ADDRESS STREET CITY STATE ZIP COUNTY FARM-RAISED DEER HERD REGISTRATION # FRDK TELEPHONE #: FRDK CELL PHONE # ( ) - ( ) - NAME OF FARM-RAISED DEER HERD VETERINARIAN PHONE # OF FARM-RAISED DEER HERD VETERINARIAN ( ) - ADDRESS OF FARM-RAISED DEER HERD VETERINARIAN STREET CITY STATE ZIP FEES Please enclose a non-refundable fee of $50. Pre-Paid online—see instruction on reverse of form Send check or money order payable to: WI DATCP, to the address listed on the top of this form. BELOW TO BE FILLED OUT BY DISTRICT TRAINING VETERINARIAN COMPLETION OF LOCATION DATE GENERAL TRAINING SESSION NAME (PRINT) SIGNATURE DISTRICT TRAINING VETERINARIAN COMPLETION OF THE WET LAB LOCATION DATE DEMONSTRATION SESSION SOURCE HERD OF FARM-RAISED DEER SAMPLED NAME ON FRDK REGISTRATION COUNTY FARM-RAISED DEER SAMPLE PREMISES STREET ADDRESS CITY STATE ZIP REFERRAL NUMBER ON VS 10-4 SUBMISSION FORM USED FOR TRAINING PASS FAIL DISTRICT TRAINING VETERINARIAN NAME (PRINT) DISTRICT TRAINING VETERINARIAN SIGNATURE DATE
AH-CD-601.docx 05/18 Wisconsin Department of Agriculture, Trade and Consumer Protection PO Box 93178, Milwaukee, WI 53293-0178 Phone: (608) 224-4872 Fax (608) 224-4871 FARM-RAISED DEER CWD TEST SAMPLE COLLECTOR APPLICATION For Owners and Eligible Representatives - For period ending June 30, 2023 s. ATCP 10.52(4), Wis. Admin. Code APPLICANT NAME APPLICANT RELATIONSHIP TO FRDK LEGAL ENTITY COUNTY APPLICANT MAILING ADDRESS STREET CITY STATE ZIP APPLICANT TELEPHONE #: ( ) - APPLICANT CELL PHONE # ( ) - APPLICANT E-MAIL APPLICANT SIGNATURE: FARM-RAISED DEER KEEPER INFORMATION LEGAL ENTITY ON FRDK REGISTRATION DOING BUSINESS AS (If different) FRDK MAILING ADDRESS STREET CITY STATE ZIP COUNTY FARM-RAISED DEER HERD REGISTRATION # FRDK TELEPHONE #: ( ) - FRDK CELL PHONE # ( ) - NAME OF FARM-RAISED DEER HERD VETERINARIAN PHONE # OF FARM-RAISED DEER HERD VETERINARIAN ( ) - ADDRESS OF FARM-RAISED DEER HERD VETERINARIAN STREET CITY STATE ZIP FEES Please enclose a non-refundable fee of $50. Pre-Paid online—see instruction on reverse of form Send check or money order payable to: WI DATCP, to the address listed on the top of this form. BELOW TO BE FILLED OUT BY DISTRICT TRAINING VETERINARIAN COMPLETION OF GENERAL TRAINING SESSION LOCATION DATE DISTRICT TRAINING VETERINARIAN NAME (PRINT) SIGNATURE COMPLETION OF THE WET LAB DEMONSTRATION SESSION LOCATION DATE SOURCE HERD OF FARM-RAISED DEER SAMPLED NAME ON FRDK REGISTRATION COUNTY FARM-RAISED DEER SAMPLE PREMISES STREET ADDRESS CITY STATE ZIP REFERRAL NUMBER ON VS 10-4 SUBMISSION FORM USED FOR TRAINING PASS FAIL DISTRICT TRAINING VETERINARIAN NAME (PRINT) DISTRICT TRAINING VETERINARIAN SIGNATURE DATE
FRDOwnerSamplerApp.docx