Supe
rvis
ing
Adu
lt: F
ill in
the S
TATE
REC
EIVI
NG S
ITE
addr
ess h
ere (
befor
e dup
licati
ng)
Part
icip
ants
your
art to
this
addr
ess.
Junior
Duck S
tamp P
rogram
Conse
rvation
and D
esign C
ontest
Entry
Form
http
://w
ww
.fws.
gov/
/bird
s/ed
ucat
ion/
juni
or-d
uck-
stam
p-co
nser
vatio
n-pr
ogra
m.p
hp
Stud
ent I
nfor
mat
ion
Plea
se p
rint c
lear
ly__
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____
_ Fi
rst N
ame
La
st N
ame
Age
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Hom
e/R
esid
ence
Mai
ling
Addr
ess
(St
reet
or P
.O. B
ox)
Em
ail
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City
Sta
te
Zi
p C
ode
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__ (
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___)
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_ (_
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__)_
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Pa
rent
Nam
e
Pa
rent
Day
time
Phon
e
and
C
ell P
hone
Entr
y In
form
atio
n
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_Ti
tle
Sp
ecie
s of
bird
(fro
m p
erm
itted
spe
cies
list
)
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_M
ediu
m U
sed
(i.e.
acr
ylic
, col
ored
pen
cil)
Con
serv
atio
n M
essa
geW
rite
a m
essa
ge e
xpla
inin
g w
hat y
ou h
ave
lear
ned
abou
t wet
land
con
serv
atio
n an
d th
e im
porta
nce
ofco
nser
ving
hab
itat f
or w
ildlif
e, o
r why
con
serv
atio
n is
impo
rtant
to y
ou. S
ampl
e m
essa
ges
on w
ebsi
te.
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_
AUTH
ENTI
CITY
AND
LIA
BILI
TY S
TATE
MENT
DO N
OT C
OPY
THE
WOR
K OF
OTH
ERS.
PLA
GIAR
ISM
IS S
ERIO
US!
STUD
ENTS
, PAR
ENTS
, AND
TEA
CHER
S, D
O NO
T SI
GN E
NTRY
FOR
M W
ITHO
UT R
EADI
NG T
HE F
OLLO
WIN
G ST
ATEM
ENT:
I h
ereb
y cer
tify th
at thi
s is m
y orig
inal w
ork a
nd no
t cop
ied or
trac
ed fr
om
publi
shed
photo
s, ma
gazin
es, b
ooks
, illus
tratio
ns, a
rtists
’ pub
lishe
d wor
ks
or ot
her m
ateria
ls pr
otecte
d by c
opyri
ght la
ws. I
unde
rstan
d tha
t the U
.S.
Fish a
nd W
ildlife
Ser
vice a
nd ot
her s
pons
ors a
re no
t res
pons
ible f
or lo
ss or
da
mage
to m
y artw
ork.
I gra
nt ex
clusiv
e righ
ts to
the U
.S. F
ish an
d Wild
life
Servi
ce an
d its
desig
nees
to us
e, alt
er, c
opy,
publi
sh, a
nd di
splay
my a
rtwor
k for
repr
oduc
tion a
nd pr
omoti
onal
purp
oses
as th
ey se
e fit w
ithou
t co
mpen
satio
n to m
e, inc
luding
the u
se of
my p
hotog
raph
if tak
en at
a re
lated
Ju
nior D
uck S
tamp p
rogr
am fu
nctio
n or s
ubmi
tted t
o a st
ate or
natio
nal
coor
dinato
r. I fu
rther
unde
rstan
d tha
t the U
.S. F
ish an
d Wild
life S
ervic
e has
the
exclu
sive r
ight to
disq
ualify
any e
ntry w
hose
authe
nticit
y is q
uesti
onab
le.
Sign
ature
of S
tuden
t ___
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____
Date
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___
Sign
ature
ofSu
pervi
sing P
aren
t ___
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_ Da
te __
____
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____
_
Sign
ature
ofSu
pervi
sing T
each
er __
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____
_ Date
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___
Grou
p I
Gr
oup I
I
Grou
p III
Gr
oup I
V
Gra
des
K-3
Gra
des4
-6
Gra
des
7-9
Gra
des
10-1
2
Gro
up (C
heck
One
)
Supe
rvis
ing
Adu
lt / T
each
er: P
leas
e fill
in th
e fo
llowi
ng in
form
atio
n (P
rint C
lear
ly)
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__
Firs
t Nam
e
Las
t Nam
e
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__
Scho
ol / S
tudio
/ Or
ganiz
ation
/ Tr
oop
Nam
e
D
aytim
e Ph
one
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____
____
____
____
__
ing A
ddre
ss
City
Sta
te Z
ip
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__
Add
ress
Plea
se ch
eck o
ne o
f the
follo
wing
:
Par
ent
Te
ache
r
Cou
nselo
r
Tro
op L
eade
r
Oth
er
For O
ffice
Use
Onl
y
Span
ish ve
rsion
of th
is en
try fo
rm on
line a
t http
://www
.fws.g
ov/m
igrato
rybird
s/pdf/
Educ
ation
/junio
r-duc
k-stam
p-co
nser
vatio
n-pr
ogra
m/Sp
anish
%20
Form
s%20
Entry
Para
una v
ersio
n esp
anola
de es
ta for
ma ht
tp://w
ww.fw
s.gov
/migr
atoryb
irds/p
df/Ed
ucati
on/ju
nior-d
uck-s
tamp-
cons
erva
tion-
prog
ram/
Span
ish%
20Fo
rms%
20En
try.pd
f
Does
stu
dent
hav
e a
Socia
l Sec
urity
or V
ISA
Imm
igra
tion
Num
ber?
Yes
/No
Is
stu
dent
a F
orei
gn E
xcha
nge
Stud
ent?
Yes
/No
Befo
re M
ailin
g Pl
ease
Rem
embe
r to:
Re
ad th
e con
test b
roch
ure.
Pr
epar
e entr
y as a
horiz
ontal
desig
n on 9
”x 12
” med
ia no
mor
e tha
n 1/4"
thick
.
Fill o
ut the
Entr
y For
m complete
ly w
ith all required
inform
ation
.
Chec
k con
tact
pho
ne n
umbe
rs fo
r acc
urac
y.
Have
stud
ent, p
aren
t, and
supe
rvisin
g adu
lt sign
the E
ntry F
orm.
Af
fix th
e Ent
ry F
orm
to th
e bac
k of t
he en
try.
Inc
lude a
comp
leted
Refe
renc
e For
m.
Confi
rm th
e add
ress
of yo
ur S
TATE
REC
EIVI
NG S
ITE.
Po
stma
rk E
ntrie
s by y
our S
tate
Dea
dlin
e. T
he fo
llowi
ng st
ates
hav
e sp
ecial
due
date
s: SC
- Ja
n 10
; MD
- Feb
1; M
A an
d NJ
- Fe
b 15
; MO,
OH,
and
VA
- Mar
1.
All o
ther
stat
es, t
errit
ories
and
DC
postm
ark b
y Mar
ch 1
5.
If yo
u ha
ve q
uest
ions
plea
se co
ntac
t you
r sta
te co
ordi
nato
r.
