Name: 

Age: 

Date of birth:

State of residency: 

Are bite protocols and emergency procedures in place? 

Is venomous keeping legal in keepers state? 

Link to state laws regaurding venomous keeping: 

Does state require a permit? 

Does individual have a valid permit?

Notes: 

Years of experience working with venomous: 

Species currently working with: 

Summary of species previously worked with: 

Notes: