Fillable Application For Alabama Resident Disabled Fishing License Form printable pdf download

APPLICATION FOR ALABAMA RESIDENT DISABLED FISHING LICENSE

An Alabama Resident Disabled Fishing License may be purchased at the main office of the License Commissioner

located at 3925-F Michael Boulevard (corner of Azalea Road and Michael Boulevard).

For mail orders, return this form with: 1) copy of Alabama driver’s license and 2) $1.00. Mail form to:

Kim Hastie, License Commissioner

P.O. Drawer 161009

Mobile, AL 36616.

Take this application to your physician. Your physician must complete the Physician’s Statement and sign this application.

PRINT OR TYPE ONLY

Name: _______________________________________________________________________________________________

Residence Address: ____________________________________________________________________________________

City: ____________________________________State: __________________________Zip: ________________________

Date of Birth: _____________________________Age: ______________Driver’s License Number: ____________________

Color of Hair: _________________Color of Eyes: _______________Height: _______________Weight: _________________

Signature: __________________________________________________Date: _____________________________________

Social Security Number*: ___________________________________Telephone Number: _____________________________

Email address (optional): _________________________________________________________________________________

*The disclosure of your social security number is required pursuant to Section 30-3-194(a) Code of Alabama, (1975), and will

be supplied to the Alabama Department of Human Resources to enforce orders of child support.

---------------------------------------------------- Physicians Only ------------------------------------------------------------

Physician’s Statement:

(Excerpt of Section 9-11-54(d), Code of Alabama, (1975) For the purposes of this section, the term “disabled” means

inability to engage in any substantial gainful activity by reason of any medically determinable physical impairment

which can be expected to result in death or in blindness or to be of long continued and indefinite duration. The term

“blindness,” as used in this section, means central visual acuity of 5/200 or less in the better eye with the use of a

corrective lens. An eye in which the visual field is reduced to five degrees or less concentric contraction shall be

considered for the purposes of this section as having a central visual acuity of 5/200 or less.

Type of disability: _____________________________________________________________________________________

If blindness, visual acuity: _______________________________ Duration of disability: ______________________________

This is to certify that the applicant named above is totally disabled as defined by Section 9-11-54(d), Code of Alabama (1975).

Name of Physician: ___________________________________________________________________________________

Signature of Physician: ________________________________________________Date: ___________________________

consv014

9/2010

Application For Alabama Resident Disabled Fishing License Form