State of Florida
Disabled Resident's Hunting/Fishing License Application
Florida Fish and Wildlife Conservation Commission
2590 Executive Center Circle, Suite 200, Tallahassee, FL  32301
(850) 488-3641

______________________________________           ____________________________________________
       (APPLICANT NAME)                                                     (SOCIAL SECURITY NUMBER)

______________________________________           ____________________________________________
       (STREET ADDRESS)                                                        (CITY)                  (STATE)      (ZIP)

HOME TELEPHONE (_____)_____________            DATE OF BIRTH_MO_____DAY_____YEAR________

SEX___  RACE__________HEIGHT_FT___IN___  WEIGHT_____ EYE COLOR_________ HAIR__________

    I do hereby attest and affirm that I am a Florida resident as defined in Chapter 372 and all the above information is true and correct.  I understand that a change of residence to another state wil invalidate this license.

___ Replacement                                                         _____________________________________  __________
                                                                                      Applicant's Signature                                           Date
___________________________________________________________________________________________
License Requirements

In order to receive a no cost Resident Disabled Person's Hunting and Fishing Certificate, applicants must attach a copy of one of the following which certifies the applicant as Totally and Permanently Disabled:
    ____ Certification by the United States Veteran's Administration
    ____ Certification by any brance of the United States Armed Forces
    ____ State of Florida-Department of Veteran's and Community Affairs - 100% Service Connected Disabled Veteran Identification Card (must have the statement total and permanent disabled)

             OR
    ____ Documentation of CURRENT eligibility for SSI of SSDI DISABILITY Benefits from Social Security Administration.

___________________________________________________________________________________________
Proof of Residency
(Copy Attached)

    ____ Florida Drivers License ("Florida Only" or Florida ID Card not acceptable)
    ____ Florida Homestead Exemption
    ____ Statement from the current Landlord

              OR
    ____ Florida Voter's Registration Card AND Florida Motor Vehicle Registration

____________________________________________________________________________________________
Hunter Safety Certification
(If born on or after June 1, 1975)
Certificate No.________________________________________ Certifying State_______________________

____________________________________________________________________________________

COUNTY USE ONLY:
County:_________N/A___________  Clerk:__________N/A____________  Date_________N/A________
              _______Hunting and Fishing                                     ______Fishing Only