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STATE OF FLORIDA

RESIDENT LIFETIME LICENSE APPLICATION

Florida Fish and Wildlife Conservation Commission

APPLICANT INFORMATION

PROOF OF RESIDENCE

NAME

If a Florida Driver’s License is not used for proof of residency, a copy of one of the

(LAST)

(FIRST)

(MI)

following documents (as proof of six months continuous residence in Florida) must be

attached.

STREET ADDRESS

____ Military orders showing that applicant is stationed in Florida

CITY

STATE

ZIP CODE

____ Florida Homestead Exemption

SOCIAL SECURITY NO.

DATE OF BIRTH

AGE

____ Florida Voter’s Registration

SEX

HEIGHT

RACE

M______ or F______

TELEPHONE

EMAIL ADDRESS

NOTE: For applicants under 18 years of age, documents may be those of the

(

)

parent/guardian.

The Florida Fish and Wildlife Conservation Commission (FWC) collects social security number (SSN)

for the issuance of recreational and professional fishing or hunting licenses or permits to an individual

in accordance with s. 372.561 F.S. and 42 USC 666 for the purposes of administration of the Title IV-D

program for child support enforcement, use by the commission, and as otherwise provided by

law.

PLEASE CHECK THE LICENSE YOU ARE APPLYING FOR

PROOF OF AGE

Lifetime

Sportsman

Hunting

Freshwater

Saltwater

Fishing

___ Certified copy of birth certificate for applicants 12 years of age and under must be

Age 0—4

___$401.50

___$201.50

___$126.50

attached. (A Birth Registration Card is not acceptable.)

Age 5– 12

___$701.50

___$351.50

___$226.50

Age 13—64

___$1001.50

___$501.50

___$301.50

FOR COUNTY USE ONLY

CERTIFICATION

CUSTOMER NUMBER ___________________________

RESIDENCY:

TRANSACTION NUMBER ________________________

I hereby attest or affirm that I have continually resided in the state of Florida for the past

DATE SOLD ___________________________________

six months and claim Florida as my primary residence and that the information provided

COUNTY ______________________________________

is true and correct. I also understand and meet the residency requirements for

purchasing a Lifetime License.

CLERK’S SIGNATURE___________________________

Hunter Safety Certification Number for under age 16 if provided.

This is optional - not required.

_____________________________________

_____________________

STATE _______________________________

Signature of Applicant/Parent/Guardian

Date

NO. __________________________________

FWC COPY

12/20/2007

Resident Lifetime License Application Form - Florida Fish And Wildlife Conservation Commission

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