Hunting Method Exemption Physician'S Statement Of Eligibility - Missouri Department Of Conservation

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Rev. 2016
MISSOURI DEPARTMENT OF CONSERVATION
Hunting Method Exemption
Physician’s Statement of Eligibility
SEND THIS PORTION TO THE MISSOURI DEPARTMENT OF CONSERVATION
Section A:
APPLICANT’S NAME (please print legibly Last, First, MI)
SOCIAL SECURITY #
DATE OF BIRTH
SEX
MO
APPLICANT’S MAILING ADDRESS
CITY OR TOWN
STATE
COUNTY
ZIP
DAYTIME TELEPHONE (
) ____________________________
SIGNATURE: _____________________________________
DATE: __________________
Section B: CHECK ALL THAT APPLY.
(Check each disability as defined in section 3CSR10-20.805(42), Wildlife Code that applies. A person’s age shall not be a factor in determining a disability.)
STATIONARY VEHICLE
□ The person is blind, as defined in section 8.700, RSMo.
□ The person cannot ambulate or walk 50 feet without stopping to rest due to a severe and disabling arthritic, neurological, orthopedic
condition, or other severe and disabling condition.
□ The person cannot ambulate or walk without the use of, or assistance from, a brace, cane, crutch, another person, prosthetic device,
wheelchair, or other assistive device.
□ The person is restricted by a respiratory or other disease to such an extent that the person’s forced respiratory expiratory volume
for one second, when measured by spirometry, is less than one liter, or the arterial oxygen tension is less than 60 mmHg on room
air at rest.
□ The person uses portable oxygen.
□ The person has a cardiac condition to the extent that the person’s functional limitations are classified in severity as Class III or Class IV
according to the standards set by the American Heart Association.
Section C:
PHYSICIAN’S NAME (please print legibly Last, First, MI)
LICENSE NUMBER
STATE OF LICENSE
MEDICAL FACILITY
ADDRESS
CITY OR TOWN
STATE
ZIP
TELEPHONE (
) ____________________________
FAX (
) ____________________________
What is the Probable Duration of the Disability? □ 6 mos □ 1yr □ 2yr □ 3yr □ 5yr
PERMANENT STATUS NO LONGER AVAILABLE
PHYSICIAN’S SIGNATURE ______________________________________________________
DATE ____________________________________
APPLICANT KEEPS THIS PORTION
CUT ALONG DOTTED LINE.
FOLD HERE
This disabled person shall mail the top portion of this form to the Department of Conservation within ten (10) days
after completion by the physician.
THIS IS YOUR CARD/STATEMENT OF ELIGIBILITY AND MUST BE IN YOUR POSSESSION WHEN HUNTING,
AND IS TO BE DISPLAYED TO ANY AGENT OF THIS DEPARTMENT UPON REQUEST.
Name ____________________________________________
Address _____________________________________________________________________________ ZIP __________
EXEMPTION: Stationary Vehicle
DURATION: □ 6 mos □ 1yr □ 2yr □ 3yr □ 5yr DATE OF ISSUE: ____________________________
Applicant’s signature ________________________________
Physician’s signature _____________________________
Renewal forms can be obtained from the Missouri Department of Conservation, P.O. Box 180, Jefferson City, MO 65102-0180; and online at mdc.mo.gov

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