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RESIDENT PERSONS WITH DISABILITIES HUNTING/FISHING LICENSE APPLICATION

FLORIDA FISH AND WILDLIFE CONSERVATION COMMISSION

2590 EXECUTIVE CENTER CIRCLE, SUITE 200, TALLAHASSEE, FL 32301

FAX: (850) 487-2065

To apply online, visit

APPLICANT INFORMATION: Please complete the boxes below. Incomplete or illegible applications cannot be processed.

Applicant Name:

Date of Birth:

Social Security Number:

Sex:

Race:

Mailing Address:

City:

State:

Zip:

Phone Number:

Email Address:

QUALIFYING METHOD: Please include one of the following qualifying methods with this application:

1. Documentation of CURRENT (dated within the last 12 months) eligibility for disability benefits from Social Security

Administration (Form SSA-1099 Not Acceptable)

2. Certification by the United States Railroad Retirement Board

3. State of Florida Department of Veterans Affairs - 100% total and permanent service connected Disabled Veteran ID Card

4. Certification by the United States Veterans Administration or any branch of the Unites States Armed Forces

5. Florida Department of Financial Services, Division of Workers Compensation (LES Form DWC-4)

6. An Order from a Judge of Compensation claims verifying total and permanent disability for purposes of Florida’s Workers

Compensation under chapter 440, F. S.

7. Written Confirmation by the carrier providing Workers Compensation benefits verifying total and permanent disability for

the purposes of Florida’s Workers Compensation under chapter 440, F.S.

PROOF OF RESIDENCY: Please include one of the following forms of Florida residency:

Florida Driver License or Florida ID Card (“Valid in Florida only” card not acceptable)

Florida Homestead Exemption

Notarized Declaration of Domicile (May be obtained from county clerk’s office)

Florida Voter’s Registration Card

LICENSE PREFERENCES: Please select from the following:

____ Fishing Only (Fresh/Salt)

____ Hunting and Fishing (Fresh/Salt): Hunter Safety Certification Number: ____________________ Certification State: ______

____ Gulf Reef Fish Angler (Required for recreational anglers fishing from a private boat off the Gulf coast for Gulf reef species)

____ Migratory Bird Permit (Please answer the below survey questions):



Select the Number of Ducks bagged last

Select the Number of Woodcock bagged

season:

last season:

Did not hunt

None

1-10

1-30

11+

31+



Select the Number of Doves bagged last

Did you hunt Coots or Snipe last season?

season:

Yes

Did not hunt



None

Did you hunt Rails or Gallinule last season?

1-30

Yes

31+

I attest that all of the above information is true and correct:

Applicant Signature: _______________________________________________ Date: ______________________________

Any person who knowingly makes a false or misleading statement in an application or certification under Section 320.0848, F.S. commits a misdemeanor

of the second degree, punishable as provided in Section 775.083, F.S.

The Florida Fish and Wildlife Conservation Commission (FWC) collects social security number (SSN) for the issuance of recreational and professional

fishing or hunting licenses or permits to an individual in accordance with 379.352 F.S. and 42 USC 666 for the purposes of administration of the Title IV-D

program for child support enforcement, use by the commission, and as otherwise provided by

law.

Rev. 02/2016

Resident Persons With Disabilities Hunting/fishing License Application Form - Florida Fish And Wildlife Conservation Commission

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