Okaloosa County BOCC — January 30, 2013 — 2013 Signed Turtle Permit — reading text

that I have the right to be represented by counsel or a qualified representative at an administrative proceeding. I also understand that I must attach a petition to this request if I have requested a hearing or an informal proceeding. Please sign and state your current address and telephone number: Signature Date PRINT NAME Phone Number The above indicated person is D the Petitioner, 0 counsel for the Petitioner, or 0 the qualified representative of the Petitioner (Please check one). Petitioner’s name and address Attorney or representative’s name and address (if applicable) Petitioner’s email address Attorney or representative’s email address If applicable, please list the type of Permit /License applied for and the Permit/License Number Please mail form to: Legal Office Florida Fish and Wildlife Conservation Commission 620 South Meridian Street Tallahassee, Florida 32399-1600 FLORIDA FISH AND WILDLIFE CONSERVATION COMMISSION PETITION FOR ADMINISTRATIVE PROCEEDING Compliance of Section 120.569(2)(c), Florida Statutes, and Chapter 28-106, Florida Administrative Code Only if challenging the agency action, please complete this form or otherwise provide the information required by Chapter 28-106, of the Florida Administrative Code and send to the following address along with the completed Election of Rights form and a copy of the challenged agency action: Legal Office Florida Fish and Wildlife Conservation Commission 620 South Meridian Street Tallahassee, Florida 32399-1600 Please list the name and address of each agency affected and each agency’s file or identification number, if known: Please identify the petitioner (the individual or organization requesting the hearing): Name: Address: Phone number: ( ) _ Please identify the petitioner’s counsel or representative (if any): Name: Address: Phone number: ( ): — [The address of petitioner’s counsel or representative, if listed above, shall be the address for service purposes during the course of the proceedings] 4. Please explain how the petitioner’s substantial interests are or will be affected by the Commission’s action or proposed action: Please explain when and how the petitioner received notice of the Commission’s action or proposed action: 6. Please indicate whether the petitioner disputes any material facts and, if so, state all disputed material facts: 7. Please concisely state the ultimate facts alleged, including a statement of the specific facts that the petitioner contends warrant reversal or modification of the Commission’s action or proposed action: 8. Please state the specific rules or statutes that the petitioner contends require reversal or modification of the Commission’s action or proposed action: 9. Explanation of how the alleged facts (7) relate to the specific Rules or Statutes (8) stated above: 10. Please state the relief sought by the petitioner, stating precisely the action that the petitioner wants the Commission to take with respect to the action or proposed action: Either the Petitioner, counsel for the Petitioner, or the qualified representative of the Petitioner must sign below agreeing that the person signing this document has read this Petition, made a reasonable inquiry, and is not filing this document for any improper purposes, frivolous purpose, or needless increase in the cost of litigation. Signature Date PRINT NAME The above indicated person is 0 the Petitioner, 0 counsel for the Petitioner, or 0 the qualified representative of the Petitioner (Please check one).