Name: Mr. Mrs. Miss  
Address:
City:   State:   Zip:
County:
Home Phone:   Work Phone:   Cell Phone:
Email:
Affiliation:
List in Directory for members:   Yes    No     
Show on website for Public:    Yes    No
Do you have a current state rehabilitation permit? YES   NO   (If yes, please include a copy)
Do you have a current federal permit? YES   NO   (If yes, please include a copy)
Do you have a current fawn permit? YES   NO   (If yes, please include a copy)
Do you have a current education permit? YES   NO   (If yes, please include a copy)

Do you have a membership in the International Wildlife Rehabilitation Council (WRNC), the
National Wildlife Rehabilitators Association (NWRA), or any other state or local rehab groups?
Please list them:

What do you rehab:
small mammals
medium-sized mammals
reptiles
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.
songbirds
raptors
waterfowl
seabirds
wading birds

MEMBERSHIP FEE $15.00
Please print this form and make your checks payable to WRNC.
Mail both the form and the check to the address below.

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