Form Application For Alabama Resident Disabled Fishing License printable pdf download

Form Application For Alabama Resident Disabled Fishing License

Application for Alabama Resident Disabled Fishing License

Take application to your physician. A physician must fill out the physicians’ statement and sign.

Return the complete application to the Probate Judge, Revenue Department or License

Commissioner in your county of residence.

PRINT OR TYPE ONLY

Social Security Number: ____-___-______

Name:___________________________________________________________

(first)

(middle)

(last)

Residence Address:_______________________________________________

City:_________________________ State: ___________ Zip Code:_________

Mailing Address

:___________________________________________

(if different)

City:_________________________ State: ___________ Zip Code:_________

County of Residence:_________________ Length of residence: __________

Date of Birth: ___/___/______ Age: _____ Drivers License Nbr:___________

Color Hair: _______ Color Eyes: ________ Height: __’ ___” Weight: ____lbs.

Signature: ______________________________________ Date: ___/___/____

PHYSICIANS ONLY

----------------------------------------

-----------------------------------

Physician’ s Statement:

(

excerpt of SECTION 9-11-54, CODE OF ALABAMA, 1975)

For the purpose of this license 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 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 ,

Code of Alabama, 1975.

Name of Physician: (

_____________________________________

type or print):

Signature of Physician: ____________________________Date:___________

Form Application For Alabama Resident Disabled Fishing License

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