Application

Candidate's name*

Parent's of candidate (if under 18)

Candidate's phone #*

Candidate's e-mail address*

Address*

Street Address Address Line 2 City State ZIP Code

Age*

Date of Birth*

MM

DD

YYYY

WDNR Class Permit*

A
B
C

WDNR Customer Number*

Please email or mail a copy of your WDNR Disabled Class Permit after you complete this form.
Badger Mining Corporation
c/o Tiffany Thoma
409 S. Church Street
Berlin, WI 54923
tthoma@badgerminingcorp.com

BMC Location(s) & Time Period(s) Interested in Hunting

St. Marie (Green Lake County)

Saturday, October 5th - Thursday, October 10th, 2019

Fairwater (Green Lake / Fond du Lac Counties)

Saturday, October 5th - Thursday, October 10th, 2019

Taylor (Jackson / Trempealeau Counties)

Monday, October 7th - Wednesday, October 9th, 2019
Thursday, October 10th - Saturday, October 12th, 2019

Merrillan (Jackson County)

Saturday, October 5th - Thursday, October 10th, 2019

Describe your condition / illness / special need / disability*

Describe your mobility & special need*

Do you want / need an assistant to accompany you during the hunt?*

Yes
No

(Note: Class C Permit Holders are required to have an assistant accompany them when hunting).

Are you in need of any assistance / medication in a 24-hour time period? Please Explain.*

Have you taken a Hunter's Safety Course?*

Yes
No

If so, when and where?*

Number of years of hunting experience?*

Type of game hunted?*

What do you want to accomplish during this hunt?*

Have you participated in the BMC Special October Gun Deer Hunt before?*

Yes
No

If yes, what year(s)*

Have you ever been convicted of a criminal offense?*

Yes
No

If the answer is yes then for each such conviction, indicate (a) the date(s) of conviction, (b) the nature of the offense, (c) the penalty imposed, (d) the circumstances involved, (e) whether the offense involved weapons, and (f) whether the conviction impacts your ability to possess or use weapons below.*

Do you have any criminal charges against you?*

Yes
No

If the answer is yes, indicate the pending charge(s) and surrounding circumstances below.*

Have you entered into a pretrial diversion or similar program relating to any criminal offense?*

Yes
No

Note: For purposes of this inquiry, "program entry" is defined as suspension or eventual dismissal of charges or criminal prosecution upon agreement to enter into treatment, rehabilitation, restitution, or other noncriminal or nonpunitive alternatives. For each such "program entry", indicate (a) the date(s) you entered into the program, (b) the nature of the offense, (c) whether you completed the required treatment, rehabilitation, restitution, or other alternatives, (d) the ultimate disposition of the charges, and (e) the circumstances involved below.*

Are you restricted from possessing or using firearms or weapons for any reason?*

Yes
No

If the answer is yes, provide a complete description of the restriction(s) and the reason for the restriction(s) below.*

Have you been diagnosed with a mental illness?*

Yes
No

If the answer is yes, indicate (a) the nature of the illness, and (b) symptoms you experience from the illness below.*

Have you ever been convicted of a fish or game violation?

Yes
No

If the answer is yes then for each such conviction, indicate (a) the date(s) of conviction, (b) the nature of the violation, (c) the penalty imposed, (d) the circumstances involved, and (e) whether the conviction impacts your ability to hunt or possess or use weapons below.*

I understand that Badger Mining Corporation may do any or all of the following to determine my eligibility to participate in the Special Hunt, and I hereby consent to the same:

1. Investigate all statements contained in this application.
2. Conduct a criminal background check.

I certify that the answers and information given in this application are true and correct to the best of my knowledge. I agree that false or misleading information given in my application may disqualify me from consideration.

Participant's Signature*

Date Signed*

MM

DD

YYYY

FOR PARTICIPANTS OF MINORITY AGE (UNDER AGE 18 AT THE TIME OF PARTICIPATION)

Parent/Guardian's Signature

Date Signed

MM

DD

YYYY

Phone

This field is for validation purposes and should be left unchanged.

Applications are due 8/1/2019 & our goal is to notify selected participants by 8/8/2019.

Candidate Application Form

BMC Location(s) & Time Period(s) Interested in Hunting