sfn6538

Transcript

1 DISABILITY TAKE ANY TYPE OF DEER GUN APPLICATION North Dakota Game and Fish Department MAIL APPLICATION TO NDGF AT: Licensing Section SFN 6538 (09/2017) 100 N. Bismarck Expressway Bismarck, North Dakota 58501-5095 Phone: 701-328-6335 INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED AND WILL BE RETURNED Applicant Name: State: City: Address: Zip Code: ND Driver’s License # or ND Nondriver Photo ID # (Required): Height: Weight: Eye Color: Hair Color: Date of Birth: Telephone Number: *Social Security Number: I, (signed below) request a permit to take any type of deer with provisions of NDCC Section 20.1-03-11(6), by being unable to step from a vehicle without aid of a wheelchair, crutch, brace, or other mechanical support or prosthetic device or who is unable to walk any distance because of a permanent lung, heart, or other internal disease that requires the person to use supplemental oxygen to assist breathing. I hereby certify that I have not been convicted of any game or fish violation within the past year or under suspension. Applicant Signature: Date: This permit converts one deer gun tag per year to an any sex or species of deer for the unit assigned on the tag. Permit NOTE: holders need to send the lottery tag to the licensing department each year to have it verified and stamped. This permit may be revoked, amended, suspended or modified at any time for cause, including but not limited to: change in permit laws or rules, change in disability eligibility, or violation of hunting, trespass or firearm. STATEMENT OF CONFIRMATION This section must be completed by a Licensed Physician only (excludes Certified Nurse Practitioner and Certified or Licensed Chiropractor. Physician Assistant) I, the undersigned, verify that the above applicant is: PLEASE CHECK ONE.  Unable to step from a vehicle without aid of a wheelchair, crutch, brace or other mechanical support or prosthetic device; or  Unable to walk any distance because of a permanent lung, heart, or other internal disease that requires the person to use supplemental oxygen to assist breathing. ____________________________ Describe the applicant’s disability or injury in detailed legible laymen terms: _____________________________________________________________________________________________ PLEASE CHECK ONE. The above verified condition is:  Permanent – there is no reasonable expectation of recovery. (Permit must be renewed every 5 years, requiring physician certification on a new application form.) (Permit is good only for the current deer season.) Temporary.  Title: Print Name: Phone #: Signature: Date: Zip: City: Name of Clinic: An individual certifying to or providing false information to the Director, for the purpose of obtaining this permit, is guilty Penalty note for Signatures: of a misdemeanor. *Social Security Number Requirement. In accordance with state law NDCC 20.1-03-35 and 42 US Code 666 (a)(13) and (16), North Dakota Game and Fish Department is required to collect social security numbers from all persons obtaining any license or permit.

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