Social Security Disability Fishing Or Hunting License Application Form

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OKLAHOMA DEPARTMENT OF WILDLIFE CONSERVATION
For Office Use Only
Street Address
Mailing address
Permit # ___________
th
2145 NE 36
St
P.O. Box 53465
Oklahoma City, OK 73111
Oklahoma City, OK 73152
Date Issued ___________
(405) 521-3852
SOCIAL SECURITY DISABILITY FISHING OR HUNTING LICENSE APPLICATION
Legal residents of Oklahoma who have resided in this state for at least six months and who are receiving
disability benefits through Social Security Disability, Supplemental Security Income (SSI), or Railroad
Retirement may purchase a disability fishing or hunting license for $10.00. Persons who are “permanently and
totally disabled” and receiving benefits through the Multiple Injury Trust Fund are also eligible for a disability
hunting or fishing license. Persons receiving disability benefits through the United States Postal Service are
eligible only for a disability fishing license. This license is valid for 5 years from the date of purchase. To
determine eligibility for this license, you must show proof of receiving disability benefits. Please see reverse
side of application for documentation requirements.
PAYMENT MUST BE MADE IN THE FORM OF A CASHIER’S CHECK OR MONEY ORDER.
____ Disability Fishing $10.00
____ Disability Hunting $10.00
PLEASE PRINT OR TYPE:
NAME ____________________________________________________________________________________________
Last Name
First Name
Middle Initial
STREET ADDRESS ________________________________________________________________________________
CITY ___________________________________, Oklahoma
ZIP CODE ____________ - _________
MAILING ADDRESS
_________________________________________________________________________
(if different)
HUNTER EDUCATION # ________________________
(Required if age 35 or under. Otherwise license will be issued with “apprentice”
designation. Not required for fishing.)
SOCIAL SECURITY NUMBER _________ - ______ - _________
DATE OF BIRTH _______/_______/_______
REQUIRED
REQUIRED
DRIVER'S LICENSE NUMBER___________________________________
EXPIRATION DATE _______/_______
HOME PHONE NUMBER (_______) _______ - __________
DAY PHONE NUMBER (_______) _______ - __________
MILITARY VETERAN ____Yes ____ No
HT _____ ft _____ in
WT ______
EYE COLOR ______
HAIR COLOR _______
I certify under penalty of perjury under the laws of the state of Oklahoma that I have been a bona fide resident of
Oklahoma for the six months immediately preceding the date of this application.
____________________________________________
_______/_______/_______
Signature of Applicant
Date
________________________________________________
Signature of Authorized Department Employee

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