Form Fg356b-2 - Free Sport Fishing License Application

California Natural Resources Agency

DEPARTMENT OF FISH AND WILDLIFE

2013 FREE SPORT FISHING LICENSE APPLICATION

IMPORTANT! INCOMPLETE OR UNSIGNED APPLICATION WILL BE RETURNED.

ALLOW 15 BUSINESS DAYS FOR PROCESSING.

Complete this application and submit along with any required verification of eligibility to the California Department of Fish and Wildlife.

FREE SPORT FISHING LICENSE:

Please check the appropriate box to show how you qualify for a Free Sport Fishing License.

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A. Blind: Any person, with central vision acuity of 20/200 or less in the better eye with the aid of the best possible correcting

glasses, or central vision acuity better than 20/200 if the widest diameter of the remaining visual field is no greater than 20

degrees. Certification of blindness by an optometrist or ophthalmologist is required. If you are renewing your license, no further

certification is required. Attach a copy of a previously issued free sport fishing license to this completed application.

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B. Mobility Impaired: Any person who is a resident of the State and who is so severely physically disabled as to be permanently

unable to move from place to place without the aid of a wheelchair, walker, forearm crutches or a comparable mobility-related

device. Attach a copy of a previously issued free sport fishing license or proof of eligibility from a licensed physician or surgeon.

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Type of mobility impairment:

Amputee

Walker/Crutches

Wheelchair

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C. Developmentally Disabled: Certification by a licensed physician or the director of a State regional center is required below.

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D. Low Income Native American: Any American Indian or lineal descendant who is a resident of the State and whose total annual

income does not exceed $11,170.00 for the head of household, plus $3,960.00 for each additional family member living with

them. Certification by Bureau of Indian Affairs (BIA) or proof of being on a tribal registry is required. If you are renewing your

license, no further certification from BIA is required. Verification of income on Form FG 371 is required yearly. Attach Form

FG 371 and a copy of last year’s free license to this completed application.

DMV/STATE ID NUMBER

STATE

GO ID NUMBER (FROM ALDS ISSUED LICENSE)

FIRST NAME

M.I.

LAST NAME

MAILING ADDRESS

CITY

STATE

ZIP CODE

HAIR COLOR

EYE COLOR

HEIGHT (Ft., In.)

WEIGHT

DATE OF BIRTH

SEX

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MALE

FEMALE

METHOD OF RESIDENCY

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I have resided continuously in California for the last six months.

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I am now on active duty with the U.S. Armed Services.

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I am a Job Corps enrollee.

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I am not a resident of California

DAY TELEPHONE

E-MAIL ADDRESS (Voluntary)

I certify under penalty of perjury that the information given on this application is true and correct to the best of my knowledge; that I have not been convicted of

any Fish and Game violation; and that I meet all of the eligibility criteria for this license.

SIGNATURE

DATE

TO BE COMPLETED BY CERTIFYING OFFICIAL

(if box A, B or C is checked)

I certify under penalty of perjury that the person applying for this license meets the requirements cited above.

SIGNATURE OF CERTIFYING OFFICIAL

DATE

NAME AND TITLE OF CERTIFYING OFFICIAL

PHYSICIAN LICENSE NUMBER OR NAME OF STATE REGIONAL CENTER

CERTIFYING OFFICIAL’S TELEPHONE NUMBER

CERTIFYING OFFICIAL’S ADDRESS

CITY

STATE

ZIP CODE

CHECK BOX(ES) FOR ADDITIONAL ITEMS YOU WISH TO PURCHASE:



ABALONE REPORT CARD – $20.86

COLORADO RIVER SPECIAL USE VALIDATION – $3.09

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NORTH COAST SALMON REPORT CARD – $5.92

OCEAN ENHANCEMENT VALIDATION – $4.89

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SECOND ROD VALIDATION – $13.39

STEELHEAD REPORT CARD – $6.70

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STURGEON FISHING REPORT CARD – $7.73

SPINY LOBSTER REPORT CARD – $9.01

Fees include 3% license buyer surcharge.

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Indicate type of payment:

Check*

Money Order

Visa

Mastercard

*Make checks or money orders payable to California Department of Fish and Wildlife

TOTAL: $

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(Please do not send cash)

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CARD #:

EXPIRATION DATE (MM/YY):

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CVC Number (On back of credit card)

I authorize CDFW to charge the agreed amount listed above to my credit card provided herein. I agree that I will pay for this purchase in accordance with the

issuing bank cardholder agreement.

PRINT NAME: (As it appears on credit card)

SIGNATURE:

DATE: (MM/DD/YYYY)

YOU MUST INCLUDE A PHOTOCOPY OF YOUR DRIVER’S LICENSE OR DMV/ID WITH THIS APPLICATION.

SUBMIT APPLICATION, INCOME VERIFICATION OR ELIGIBILITY DOCUMENTATION AND PAYMENT TO A

DEPARTMENT OF FISH AND WILDLIFE OFFICE LISTED ON BACK.

FG356b-2 (Rev.1/13)