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:
1.
Florida Driver License or Florida ID Card (“Valid in Florida only” card not acceptable)
2.
Florida Homestead Exemption
3.
Notarized Declaration of Domicile (May be obtained from county clerk’s office)
4.
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:
o
o
Did not hunt
Did not hunt
o
o
None
None
o
o
1-10
1-30
o
o
11+
31+
Select the Number of Doves bagged last
Did you hunt Coots or Snipe last season?
o
season:
Yes
o
o
Did not hunt
No
o
None
Did you hunt Rails or Gallinule last season?
o
o
1-30
Yes
o
o
31+
No
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