Notice: Completion of this form is required to satisfy annual reporting requirements under Federal Incidental Take Permit No. TE10064. Personally identifiable information collected will be used for program administration and may be provided to requesters as required by Wisconsin's Open Records law [ss. 19.31-19.39, Wis. Stats.].

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Full name of person completing the form

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Email of person completing the form

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Date work was conducted

Date

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Which partner are you representing?

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Select protocol being used

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Number of acres or linear feet associated with protocol

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Which option are you choosing for incidental take coverage

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