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2010 BIRD SANCTUARY APPLICATION
Revised 1/2002
Name:_______________________________________ Date:______________________________
Address_____________________________________ Phone:_____________________________
______________________________________ EMAIL_____________________________
Member of_____________________________Garden Club District__________________________
Approximate size of sanctuary:_________________________________________________________
Location (Individual or Club Sanctuary):_________________________________________________
________________________________________________________________________________
There are four requirements for a bird sanctuary: Year round food, Water or moisture, Cover and Shelter
YEAR ROUND FOOD: List trees, schrubs, flowers, etc. that exist on your site that provide food for birds.
List varieties of feeders provided and types of food used in each:____________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
WATER OR MOISTURE: Natural and other sources (summer and winter)________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
COVER: List existing trees, shrubs, vines or shelter that are adaptable for cover:___________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
SHELTER: List types of artificial house, nesting boxes or protection that you have provided:________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
We have inspected this sanctuary and recommend it for certification:
Club President:___________________________________________________________________
(signature)
Club Bird Chairman:________________________________________________________________
(signature)
Chairman’s Address_______________________________________________________________
________________________________Phone______________________EMAIL______________
Name (s)________________________________________________________________________
(As it or they should appear on the certificate – PLEASE PRINT)
Date of Dedication___________________________________By Whom______________________
IMPORTANT: MAIL TO YOUR DISTRICT BIRD CHAIRMAN NO LATER THAN JULY 1
