"Resident Lifetime Fishing License for the Blind Application Form" - Montana

Resident Lifetime Fishing License for the Blind Application Form is a legal document that was released by the Montana Department of Fish, Wildlife and Parks - a government authority operating within Montana.

Form Details:

  • The latest edition currently provided by the Montana Department of Fish, Wildlife and Parks;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Fish, Wildlife and Parks.

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Download "Resident Lifetime Fishing License for the Blind Application Form" - Montana

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Resident Lifetime Fishing
License for the Blind
Application
fwp.mt.gov
All information is mandatory
Date of Birth _________/_________/_________
MM
DD
YYYY
Name First
MI
Last
Jr. Sr.
Home Phone
Work Phone
(Your application cannot be processed if you list only a PO Box Number)
Mailing Address
Physical Address
M
City
State
Zip Code
Yes FWP receives requests for mailing lists. Do you want your
A
No name included on lists provided by FWP to requestors? (see below)
N
Female
Weight
Height
Hair
Eyes
Occupation
D
Male
A
A Photocopy of your valid
Montana Identification Card must be attached.
T
O
Yes, I have attached the mandatory photocopy of my Montana Identification Card.
R
I hereby declare that I have been a legal resident of the State of Montana for a period of at least 180
Y
consecutive days (six months) immediately prior to making application for this license.
__________Years __________Months of Montana residency
(This information is REQUIRED.)
I hereby declare that all statements on this form are true and correct. I have not made more than one
application per license. I understand that if I subscribe to any false statement in this application that I
am subject to criminal prosecution. MCA 87-6-302, 303 and 304.
X
___________________________________________________________________________
____________________________________
SIGNATURE OF
APPLICANT—Original Signature
Required—Do Not Print
Date
(Faxed or photocopied signature not acceptable.)
Section 2 —
This section must be completed by a licensed physician (Ophthalmologist or
Optometrist)
I hereby certify that the above-named person is blind as defined by state law, Section 53-7-301, which reads:
(a) “Blind individual” means a visual disability in which:
(i) a person’s central visual acuity does not exceed 20/200 in the better eye with correcting lenses; or
(ii) a person’s visual field at the widest diameter subtends an angle no greater than 20 degrees.
(b) the term includes any visual disability that, in the determination of Dept. of Public Health & Human Services, renders
vision seriously defective or causes blindness.
I have read and understand the eligibility criteria listed above. Based on this criteria, I certify the applicant
listed is eligible for a Resident Lifetime Fishing License for the Blind. MCA 87-2-803 (6)
Physician’s Signature
PRINT — Physician’s Name
Physician’s License #
PRINT — Physician’s Address
$10
Resident Lifetime Fishing License
One-time
$2
Aquatic Invasive Species Prevention Pass (AISPP see reverse) This is a yearly fee
Return completed application to:
Montana Fish, Wildlife & Parks
Enclosed is my $12.00 payment in the form of a
ATTN: Information Center
:
Personal Check – Cashier’s Check – Money Order
1420 East 6th Avenue
Please make payable to MT FWP
PO Box 200701
Number _____________________________Amount $_______________
Helena, MT 59620-0701
Resident Lifetime Fishing
License for the Blind
Application
fwp.mt.gov
All information is mandatory
Date of Birth _________/_________/_________
MM
DD
YYYY
Name First
MI
Last
Jr. Sr.
Home Phone
Work Phone
(Your application cannot be processed if you list only a PO Box Number)
Mailing Address
Physical Address
M
City
State
Zip Code
Yes FWP receives requests for mailing lists. Do you want your
A
No name included on lists provided by FWP to requestors? (see below)
N
Female
Weight
Height
Hair
Eyes
Occupation
D
Male
A
A Photocopy of your valid
Montana Identification Card must be attached.
T
O
Yes, I have attached the mandatory photocopy of my Montana Identification Card.
R
I hereby declare that I have been a legal resident of the State of Montana for a period of at least 180
Y
consecutive days (six months) immediately prior to making application for this license.
__________Years __________Months of Montana residency
(This information is REQUIRED.)
I hereby declare that all statements on this form are true and correct. I have not made more than one
application per license. I understand that if I subscribe to any false statement in this application that I
am subject to criminal prosecution. MCA 87-6-302, 303 and 304.
X
___________________________________________________________________________
____________________________________
SIGNATURE OF
APPLICANT—Original Signature
Required—Do Not Print
Date
(Faxed or photocopied signature not acceptable.)
Section 2 —
This section must be completed by a licensed physician (Ophthalmologist or
Optometrist)
I hereby certify that the above-named person is blind as defined by state law, Section 53-7-301, which reads:
(a) “Blind individual” means a visual disability in which:
(i) a person’s central visual acuity does not exceed 20/200 in the better eye with correcting lenses; or
(ii) a person’s visual field at the widest diameter subtends an angle no greater than 20 degrees.
(b) the term includes any visual disability that, in the determination of Dept. of Public Health & Human Services, renders
vision seriously defective or causes blindness.
I have read and understand the eligibility criteria listed above. Based on this criteria, I certify the applicant
listed is eligible for a Resident Lifetime Fishing License for the Blind. MCA 87-2-803 (6)
Physician’s Signature
PRINT — Physician’s Name
Physician’s License #
PRINT — Physician’s Address
$10
Resident Lifetime Fishing License
One-time
$2
Aquatic Invasive Species Prevention Pass (AISPP see reverse) This is a yearly fee
Return completed application to:
Montana Fish, Wildlife & Parks
Enclosed is my $12.00 payment in the form of a
ATTN: Information Center
:
Personal Check – Cashier’s Check – Money Order
1420 East 6th Avenue
Please make payable to MT FWP
PO Box 200701
Number _____________________________Amount $_______________
Helena, MT 59620-0701
Montana Fish, Wildlife & Parks receives requests for mailing lists.
Mailing Lists -
**Please note, even if you chose no, under state law the department is required to
allow individuals who wish to compile their own mailing list access to department
records including your name, address, gender, residency status, license type, district
applied for and whether you were successful.
Aquatic Invastive Species Prevention Pass (AISPP)
Montana’s 2017 Legislature passed a law that helps fund the Aquatic Invasive
Species Prevention Program for the State of Montana (SB 363).
This law requires that to be eligible to fish in Montana, individuals must obtain the
AISPP in addition to their fishing license. The AISPP must be purchased once
each license year.
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