Wildlife Rehabilitators of North Carolina Home
Membership Application    

*First Name:  *Last Name:   
*Address:  Address2: 
*City:  *State:   
*Zip Code:  Affiliation:   
*E-mail:  *County:   i.e. Wake, Guilford  
**Home Phone:  **Work Phone:   
**Cell Phone:  Do you want to be in the directory for members:   
Do you want the public to have access to your information?:  Yes means you will show on the membership list seen by the public when they are looking for a rehabilitator. No means you will not be shown on the public list.
Permits Held:        
State Permit
Fawn Permit  
Federal Permit
Falconry Permit  
Education Permit      
     Rehab Species Categories:        
Mid-sized Mammals  
Venomous Snakes  
  You must have a federal permit or be a subpermittee on someone else's permit to be listed as accepting birds. You will be allowed to list a group below only if you are designated as being covered by a federal permit.
Wading Birds  
  2nd member of a family membership      
First Name: 
Last Name: 
After filling out this form, click on the 'Submit' button below to continue with registration for the symposium on the CE Office site.

* Required items,
** One phone number is required


Wildlife Rehabilitators of North Carolina