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New York State Angler Achievement Awards<br />

Official Entry Form<br />

Section A: Entry Category<br />

Fish is being entered in<br />

(check one)<br />

Catch and Release Category<br />

(complete sections B, C, G)<br />

Annual Award Category<br />

(complete sections B, C, D, E, G)<br />

State Record<br />

(complete sections B, C, D, E, F, G)<br />

Section B: Angler Information<br />

Name of Angler: Phone: Email:<br />

Address: City/Town: State: Zip Code:<br />

Section C: Catch Information<br />

Fish Species: Kept: Released: Date of Catch: Time of Catch: AM PM (Circle one)<br />

Name of<br />

Water Body:<br />

County: Nearest Town: Length:<br />

Lure/Bait Used:<br />

Lure Color/Size:<br />

Brief description of<br />

how fish was caught:<br />

Section D: Weight Information: (Annual Award or State Record entries only)<br />

Name of Weigher: Business Name: Weight: lbs: oz:<br />

Weights taken on<br />

personal/handheld scales<br />

are ineligible.<br />

Address of Business:<br />

Phone:<br />

City/Town: State: Zip Code:<br />

Scale Certification Number: Date Last Certified: Date:<br />

Weigher<br />

Signature:<br />

Section E: Witness Verification (Annual Award or State Record entries only)<br />

Name of Witness:<br />

Address of Witness:<br />

Witness Signature:<br />

Phone:<br />

City/Town: State: Zip Code: Date:<br />

Section F: Species Information (State Record Entries Only—to be completed by a DEC Fisheries Biologist or Designee)<br />

I have examined the fish described above and confirm that it is a:<br />

Name of DEC Fisheries Biologist or Designee:<br />

Signature:<br />

Date:<br />

Section G: Angler Signature (all entries) and Notarization (State Record Entries only)<br />

I hereby swear that the information provided on this form is true and correct to the best of my knowledge and that the taking of the fish described above was<br />

in accordance with the rules of the New York State Angler Achievement Awards Program. Furthermore, I release to the New York State Department of Environmental<br />

Conservation the right to use the above information and any enclosed photographs for promotional purposes, although I understand that this does not<br />

restrict my use of the same information and photographs.<br />

Signature of Angler (all entries):<br />

Sworn before me this day of:<br />

Year:<br />

Signature of Notary (State Record entries only):<br />

Notary Seal (State Record Entries Only)<br />

Miscellaneous Notes<br />

64<br />

2016–2017 New York Freshwater Fishing Guide

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