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Samson's Ridge

Thank you for your patronage from management and staff

Please, fill out, then mail or fax to the address listed at the bottom. Please remember a deposit is required to secure your hunt.

Application for Permit and Hunting License: Your personal information is considered CONFIDENTIAL and is  used only to obtain our Permit and Hunting License. This information is then shredded.

PERSONAL DATA FOR REQUIRED PERMIT
Individual Hunt

Or with the party of:  

  Number in this party:  

Please submit individual copies for each hunter
Requested hunt date first choice: second choice:
Class of Deer

Full Name: Home Phone No.:
Address: County:
City: Email:
St:   Zip: Social Security Number:
SSN is mandatory pursuant to 42 U.S.C. 660(0)(13) & 5 ILCS 100/10-65© for the use under the State’s Child Support Enforcement Program
Driver’s License No.: Issue date:
Date of birth: Exp. Date:
Race: Caucasian    African American    Hispanic    other   
Gender:    Height:  ft  in.   Weight: lbs.
Hair color: Eye color:
In case of emergency please list an immediate contact:
Name: Home phone no.:
Office phone no.: Cell no.:

I, , have voluntarily provided this personal information to Samson’s Ridge to obtain the necessary Permits for Hunting, on this day of .

CONFIRMATION TO BE SENT TO CONFIRM YOUR BOOKING DATE

This information may be placed on file for further use of obtaining necessary permits for the purpose of hunting at Samson’s Ridge. ______(initial)

OR I oppose of my personal information being kept on file for further use. ______(initial)
I request this information be destroyed after obtaining necessary permit.
Signature:  
Print Name:   Date:

Len Rudd, Owner • 5156 Old Marion Road • Metropolis, IL 62960-3527
Office: 618-524-8977 • fax: 618-524-9837 • Cell: 270-994-2553

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