MAINE BOWHUNTERS ASSOC.
                                                    P.O. Box 5026
                                         August, Maine 04332-5026

APPLICATION FOR ADVANCED BOWHUNTER PROGRAM
           PLEASE PRINT NEATLY



Last Name __________________________________________________ Date ________________

First Name _______________________________________________________ M.I. __________

Mailing Address __________________________________________________________________

Street Address ___________________________________________________________________

City/Town __________________ State _______ Zip Code _________ County _____________

Telephone (home) _____________________ E-mail Address ____________________________

Drivers License Number (For background check only) _______________________________

Bowhunter Safety Certificate Number _________________ Current MBA member? YES   NO

YES   NO   Have you ever had a revocation of ANY license issued by IF&W in the past
           10 years?

YES   NO   Have you been convicted of ANY IF&W law violation? If so, give date(s) 
           and a brief explanation. 
           _______________________________________________________________________
           _______________________________________________________________________
 
YES   NO   Are you a convicted felon?

YES   NO   Have you legally tagged a big game animal, harvested with a bow, in 
           Maine, within the past 4 years? 
           If yes, fill in data below. Put the number of animals harvested in the 
           corresponding line.

DEER ____ YEAR(S) _____________ Tagging Station Location _________________________
BEAR ____ YEAR(S) _____________ Station Location _________________________________
MOOSE ____ YEAR(S) _____________ Station Location ________________________________
TURKEY _____ YEAR(S) ____________ Station Location _______________________________

By signing this application, I do solemnly swear that the above information is 
correct, and give my permission to the MBA to verify information with the DIF&W
and local authorities.

Signature: _____________________________________________ Date: __________________

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FOR INSTRUCTOR USE ONLY

Instructor Name: _________________________________________ Card issued?   YES   NO

If not, please state reason: _____________________________________________________