Form BA-116 "Disabled Persons Motor Vehicle Hunting Permit Application" - Idaho

What Is Form BA-116?

This is a legal form that was released by the Idaho Department of Fish and Game - a government authority operating within Idaho. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the Idaho Department of Fish and Game;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form BA-116 by clicking the link below or browse more documents and templates provided by the Idaho Department of Fish and Game.

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Download Form BA-116 "Disabled Persons Motor Vehicle Hunting Permit Application" - Idaho

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BA-116
THIS FORM MAY BE PHOTOCOPIED
DISABLED PERSONS MOTOR VEHICLE HUNTING PERMIT
(Application)
DOCTOR/P.A./N.P. CERTIFICATION
Before completing this application please read Idaho
I do hereby certify that the above named applicant is
Code 36-1101(b) and Commission Regulations IDAPA
disabled as checked below and defined in Idaho Code 36-
13.01.04.303 and 13.01.04.010 summarized on the reverse
1101(b); and that I am a physician, physician’s assistant, or
side.
nurse practitioner licensed to practice in the United States
Please complete, sign and return this application along
or Canada.
with $1.75 issuance fee to any Department office listed on
Patient has lost the use of one (1) or both lower
the reverse side of this application for issuance of a permit
extremities or both hands, or is unable to walk two
to hunt from a motor vehicle. Please type or print legibly.
hundred (200) feet or more unassisted by another
A DOCTOR, P.A., or N.P.’S CERTIFICATION ON THIS FORM
person, or is unable to walk two hundred (200) (feet or
IS REQUIRED.
more without the aid of a walker, cane, crutches, braces,
prosthetic device or a wheelchair, or is unable to walk
two hundred (200) feet or more without great difficulty
Please Print
or discomfort due to one or more of the following
impairments: neurological, orthopedic, respiratory,
I, First Name, Initial ________________________________
cardiac, arthritic disorder, blindness, or the loss of function
or absence of a limb.
Last Name _______________________________________
Street Address ___________________________________
q 
q 
Long
Short Term
City ________________State __________ Zip __________
If short term, expected date of recovery _______________
Gender _________ Phone Number __________________
Please Print or Type Legibly
Date of Birth (mm/dd/yyyy) ________________________
Doctor, P.A.,
SSN (Required by Law) ___________- _______- ________
or N.P.’s Name ____________________________________
Current Year’s
City ______________________ State _________________
Hunting License No. _______________________________
Physician, P.A.,
or N.P’s Signature _________________________________
Driver’s License No. _______________________________
DL Ex Date ______________________________________
PHYSICIANS, PHYSICIAN’S ASSISTANT, OR NURSE
I affirm that I am capable of holding and firing, without
PRACTITIONER NOT LICENSED TO PRACTICE IN
assistance from other persons, legal firearms or archery
IDAHO MUST SEND A PHOTOCOPY OF THEIR MEDICAL
equipment; and that I qualify for this permit.
LICENSE OR HAVE THEIR SIGNATURE NOTARIZED BELOW.
On this day ______________, 20___ before me, the
undersigned, a Notary Public for the state of_________,
residing in _______________ county, personally appeared
Signature of Applicant
known to me to be the person whose name is subscribed
to the within instrument, and acknowledgement to me
that ___________ executed the same. IN WITNESS
WHEREOF, I have here unto set my hand and affixed my
Printed Name
official seal the date and year first hereinabove written:
_______________________________________________
My Commission Expires____________________________
Date
ANY PERSON WILLFULLY MAKING FALSE STATEMENTS IN THIS
ANY PERSON WILLFULLY MAKING FALSE STATEMENTS IN THIS
FORM SHALL BE GUILTY OF A CRIMINAL MISDEMEANOR AND
FORM SHALL BE GUILTY OF A CRIMINAL MISDEMEANOR AND
THE LICENSE ISSUED TO SUCH APPLICANT SHALL BE VOID
THE LICENSE ISSUED TO SUCH APPLICANT SHALL BE VOID
AND OF NO EFFECT FROM ITS DATE OF ISSUANCE.
AND OF NO EFFECT FROM ITS DATE OF ISSUANCE.
This Portion to be Completed by Issuing Fish and Game Office
Number of Permit _________________________________ Issued by ____________________________________
Vendor Number ____________________________________________________ Date ______________________
UPDATED 5/21
THIS FORM MAY BE PHOTOCOPIED
BA-116
THIS FORM MAY BE PHOTOCOPIED
DISABLED PERSONS MOTOR VEHICLE HUNTING PERMIT
(Application)
DOCTOR/P.A./N.P. CERTIFICATION
Before completing this application please read Idaho
I do hereby certify that the above named applicant is
Code 36-1101(b) and Commission Regulations IDAPA
disabled as checked below and defined in Idaho Code 36-
13.01.04.303 and 13.01.04.010 summarized on the reverse
1101(b); and that I am a physician, physician’s assistant, or
side.
nurse practitioner licensed to practice in the United States
Please complete, sign and return this application along
or Canada.
with $1.75 issuance fee to any Department office listed on
Patient has lost the use of one (1) or both lower
the reverse side of this application for issuance of a permit
extremities or both hands, or is unable to walk two
to hunt from a motor vehicle. Please type or print legibly.
hundred (200) feet or more unassisted by another
A DOCTOR, P.A., or N.P.’S CERTIFICATION ON THIS FORM
person, or is unable to walk two hundred (200) (feet or
IS REQUIRED.
more without the aid of a walker, cane, crutches, braces,
prosthetic device or a wheelchair, or is unable to walk
two hundred (200) feet or more without great difficulty
Please Print
or discomfort due to one or more of the following
impairments: neurological, orthopedic, respiratory,
I, First Name, Initial ________________________________
cardiac, arthritic disorder, blindness, or the loss of function
or absence of a limb.
Last Name _______________________________________
Street Address ___________________________________
q 
q 
Long
Short Term
City ________________State __________ Zip __________
If short term, expected date of recovery _______________
Gender _________ Phone Number __________________
Please Print or Type Legibly
Date of Birth (mm/dd/yyyy) ________________________
Doctor, P.A.,
SSN (Required by Law) ___________- _______- ________
or N.P.’s Name ____________________________________
Current Year’s
City ______________________ State _________________
Hunting License No. _______________________________
Physician, P.A.,
or N.P’s Signature _________________________________
Driver’s License No. _______________________________
DL Ex Date ______________________________________
PHYSICIANS, PHYSICIAN’S ASSISTANT, OR NURSE
I affirm that I am capable of holding and firing, without
PRACTITIONER NOT LICENSED TO PRACTICE IN
assistance from other persons, legal firearms or archery
IDAHO MUST SEND A PHOTOCOPY OF THEIR MEDICAL
equipment; and that I qualify for this permit.
LICENSE OR HAVE THEIR SIGNATURE NOTARIZED BELOW.
On this day ______________, 20___ before me, the
undersigned, a Notary Public for the state of_________,
residing in _______________ county, personally appeared
Signature of Applicant
known to me to be the person whose name is subscribed
to the within instrument, and acknowledgement to me
that ___________ executed the same. IN WITNESS
WHEREOF, I have here unto set my hand and affixed my
Printed Name
official seal the date and year first hereinabove written:
_______________________________________________
My Commission Expires____________________________
Date
ANY PERSON WILLFULLY MAKING FALSE STATEMENTS IN THIS
ANY PERSON WILLFULLY MAKING FALSE STATEMENTS IN THIS
FORM SHALL BE GUILTY OF A CRIMINAL MISDEMEANOR AND
FORM SHALL BE GUILTY OF A CRIMINAL MISDEMEANOR AND
THE LICENSE ISSUED TO SUCH APPLICANT SHALL BE VOID
THE LICENSE ISSUED TO SUCH APPLICANT SHALL BE VOID
AND OF NO EFFECT FROM ITS DATE OF ISSUANCE.
AND OF NO EFFECT FROM ITS DATE OF ISSUANCE.
This Portion to be Completed by Issuing Fish and Game Office
Number of Permit _________________________________ Issued by ____________________________________
Vendor Number ____________________________________________________ Date ______________________
UPDATED 5/21
THIS FORM MAY BE PHOTOCOPIED
BA-116
THIS FORM MAY BE PHOTOCOPIED
IDAHO CODE 36-1101(b)
IDAPA 13.01.04.010 AND 13.01.04.303 DISABLED
PERSONS MOTOR VEHICLE HUNTING PERMITS
METHODS PROHIBITED - EXCEPTIONS. It is a
misdemeanor, except as may be otherwise provided under
13.01.04.010 Definitions
this title or commission regulations, promulgated pursuant
Disabled. A disabled person is defined as a person
thereto, for any person to take any of the game animals,
meeting criteria set forth in Sections 36-406(g), or 36-
birds or fur bearing animals of this state and provided
1101(b), Idaho Code.
further it is a misdemeanor for any person to:
Permanent Disability. Permanent disability is defined
(1) Hunt from Motorized Vehicles. Hunt any of the game
as a medically determinable physical impairment which
animals or game birds of this state from or by the use
a physician has certified that the condition has no
of any motorized vehicle; provided however, that the
expectation for a fundamental or marked change at any
commission shall promulgate rules and regulations
time in the future.
which shall allow a physically disabled person to apply
for a special permit which would allow the person to
13.01.04.303.01 Applications
hunt from a motorized vehicle which is not in motion. A
a.  Applications for disabled motor vehicle hunting permits
physically disabled person means a person:
will be on a form prescribed by the Department,
Patient has lost the use of one (1) or both lower
completed and signed by the applicant, or an individual
extremities or both hands, or is unable to walk two
may present their valid Idaho driver’s license in lieu
hundred (200) feet or more unassisted by another
of the prescribed Department form if the individual
person, or is unable to walk two hundred (200) feet or
meets the disability requirements of Section 49-117(7)
more without the aid of a walker, cane, crutches, braces,
(b), Idaho Code, except for blindness, and the driver’s
prosthetic device or a wheelchair, or is unable to walk
license is appropriately marked as disabled.
two hundred (200) feet or more without great difficulty
b.  Each application submitted on the Department
or discomfort due to one or more of the following
form shall be accompanied by certification from the
impairments: neurological, orthopedic, respiratory,
applicant’s physician, physician assistant, or nurse
cardiac, arthritic disorder, blindness, or the loss of function
practitioner stating which of the criteria set forth in
or absence of a limb.
Section 36- 1101, Idaho Code, qualifies the applicant
The commission shall specify the forms of application
and why, along with the applicant’s certification
for and design of the special permit that shall allow a
that the applicant is capable of holding and firing,
physically disabled person to hunt from a motorized
without assistance from other persons, legal hunting
vehicle that is not in motion. A fee of $1.75 shall be
equipment. If the physician, physician assistant, or
charged for the issuance of the special permit and the
nurse practitioner is not licensed to practice in Idaho,
issuance of a special permit shall not exempt a person
a copy of the physician, physician assistant, or nurse
from otherwise properly purchasing or obtaining other
practitioner’s medical license must accompany the
necessary licenses, permits and tags in accordance with
application. Physicians, physician assistants, or nurse
this title and rules and regulations promulgated pursuant
practitioners must check the appropriate box for
thereto. The special permit shall not be transferable and
short-term or long-term disability on the application.
may only be used by the person to whom it is issued. A
If the disability is short term and physical mobility is
person who has been issued a special permit which allows
expected to improve, the physician, physician assistant,
a physically disabled person to hunt from a motorized
or nurse practitioner must include a date when the
vehicle not in motion shall have that permit prominently
disability is expected to end.
displayed on any vehicle the person is utilizing to hunt
13.01.04.303.02 Permits
from and the persons shall produce, on demand, the
permit and other identification when so requested by
a.  Disabled motor vehicle hunting permits will expire no
a conservation officer of the department of Fish and
later than December 31 of the fifth year following the
Game. A person possessing a special permit shall not
date of issuance.
discharge any firearm from or across a public highway.
b.  The permit shall be prominently displayed on any
Any unauthorized use of the special permit shall be a
vehicle from which the person is hunting, on the
misdemeanor and shall be grounds for revocation of the
driver’s side of the dashboard of the parked vehicle,
permit.
suspended from the rearview mirror, or otherwise
displayed so as to be in plain view of any person
looking at the vehicle or through any windshield.
UPDATED 5/21
THIS FORM MAY BE PHOTOCOPIED
BA-116
THIS FORM MAY BE PHOTOCOPIED
IDAHO DEPARTMENT OF FISH AND GAME
HEADQUARTERS OFFICE - LICENSING SECTION
License Operations Manager
600 South Walnut St.
P.O. Box 25
Boise, ID 83707
Phone (208) 334-3700
PANHANDLE
SOUTHEAST
REGION OFFICE
REGION OFFICE
2885 W. Kathleen Ave.
1345 Barton Rd.
Coeur d’Alene, ID 83815
Pocatello, ID 83204
Phone (208) 769-1414
Phone (208) 232-4703
CLEARWATER
UPPER SNAKE
REGION OFFICE
REGION OFFICE
3316 16th St.
4279 Commerce Circle
Lewiston, ID 83501
Idaho Falls, ID 83401
Phone (208) 799-5010
Phone (208) 525-7290
SOUTHWEST
SALMON
REGION OFFICE
REGION OFFICE
15950 N. Gate Blvd
99 Hwy. 93 N.
Nampa, ID 83687
Salmon, ID 83467
Phone (208) 465-8465
Phone (208) 756-2271
McCALL
SUBREGION OFFICE
555 Deinhard Lane
McCall, ID 83638
Phone (208) 634-8137
MAGIC VALLEY
REGION OFFICE
319 South 417 East,
U.S. Highway 93 Business Park
Jerome, ID 83338
Phone (208) 324-4359
UPDATED 5/21
THIS FORM MAY BE PHOTOCOPIED
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