Form LTL-NONDIS "Non-resident Disabled Lifetime Saltwater Fishing License Application" - Virginia

What Is Form LTL-NONDIS?

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

Form Details:

  • Released on August 1, 2018;
  • The latest edition provided by the Virginia Department of Wildlife Resources;
  • 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 LTL-NONDIS by clicking the link below or browse more documents and templates provided by the Virginia Department of Wildlife Resources.

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Download Form LTL-NONDIS "Non-resident Disabled Lifetime Saltwater Fishing License Application" - Virginia

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D
G
I
F
EPARTMENT OF
AME AND
NLAND
ISHERIES
L
L
S
IFETIME
ICENSE
ALES
P.O. B
2978
OX
H
, VA 23228-9700
ENRICO
866-721-6911
(Hearing impaired call TDD# 804-367-1278)
Commonwealth of Virginia
Non-Resident Disabled Lifetime Saltwater Fishing License Application
Instructions and Lifetime License Information on page 2 (Allow up to 45 days for processing)
All fields with an asterisk * are required below:
DGIF Customer ID#: _______________________________
*Are you a United States Citizen?
Yes
No-If No, Provide your Visa or Green Card #: ________________________
*Applicant’s Name: _________________________________________________________ *Gender:
Male
Female
(Please Print)
First
Middle Initial
Last Name
*State issued Driver’s or Identification number last 4 digits: __________ *Last 4 digits of Social Security No: ___________
*Telephone: ________- ________-__________ (Cell, Home, Work, Other) *Date of Birth: ________/________/________
*Mailing Address: _____________________________________________________________________________________
*City: ____________________________________________State: _______________
Zip: ____________- ___________
*Physical Address (if different from Mailing): _______________________________________________________________
E-mail Address: _______________________________________________________________________________________
Select License(s)
Price
Non-Resident Disabled Lifetime License available below:
$ 10.00
SALTWATER LIFETIME LICENSE for Virginia Salt Water
$ 10.00
Upgrade your lifetime license to Hard Durable Plastic card w/design
$___.__
Contribute to Hunters for the Hungry:
$2.00
$5.00
$10.00
$20.00
$50.00
$__________.____
TOTAL AMOUNT DUE
Proof of Residency:
Please include a photocopy of ONE of these documents.
Required to confirm residency by providing a readable photocopy of one of the documents listed below
Valid State issued driver’s license
Valid State issued Identification card
Permanent and Total Disability
Required documentation
Defined under Code of Virginia
§ 58.1-3217. Permanently and totally disabled defined.
For purposes of this article, the term "permanently and totally disabled" shall mean unable to engage in any substantial
gainful activity by reason of any medically determinable physical or mental impairment or deformity which can be expected
.
to result in death or can be expected to last for the duration of such person's life
I have included my Physician’s Affidavit for a Disabled Lifetime License from a licensed physician.
The physician’s affidavit form can be found on our website at:
http://www.dgif.virginia.gov/forms/PERM/PERM-
034.pdf
address or you may call VDGIF License Sales and Information at 1-866-721-6911 to obtain the form.
Applicant’s Certification
By signing this application, I certify that in accordance with Virginia Code § 58.1-3217. Permanently and totally disabled
defined. NOTE: Any person who knowingly makes a false statement in order to secure a license shall be guilty of a Class
2 misdemeanor, punishable by up to six months in jail, a fine of up to $1,000 or both.
Signature: _____________________________________________ Date: _____________________________
LTL-NONDIS 0818
Page 1 of 2
D
G
I
F
EPARTMENT OF
AME AND
NLAND
ISHERIES
L
L
S
IFETIME
ICENSE
ALES
P.O. B
2978
OX
H
, VA 23228-9700
ENRICO
866-721-6911
(Hearing impaired call TDD# 804-367-1278)
Commonwealth of Virginia
Non-Resident Disabled Lifetime Saltwater Fishing License Application
Instructions and Lifetime License Information on page 2 (Allow up to 45 days for processing)
All fields with an asterisk * are required below:
DGIF Customer ID#: _______________________________
*Are you a United States Citizen?
Yes
No-If No, Provide your Visa or Green Card #: ________________________
*Applicant’s Name: _________________________________________________________ *Gender:
Male
Female
(Please Print)
First
Middle Initial
Last Name
*State issued Driver’s or Identification number last 4 digits: __________ *Last 4 digits of Social Security No: ___________
*Telephone: ________- ________-__________ (Cell, Home, Work, Other) *Date of Birth: ________/________/________
*Mailing Address: _____________________________________________________________________________________
*City: ____________________________________________State: _______________
Zip: ____________- ___________
*Physical Address (if different from Mailing): _______________________________________________________________
E-mail Address: _______________________________________________________________________________________
Select License(s)
Price
Non-Resident Disabled Lifetime License available below:
$ 10.00
SALTWATER LIFETIME LICENSE for Virginia Salt Water
$ 10.00
Upgrade your lifetime license to Hard Durable Plastic card w/design
$___.__
Contribute to Hunters for the Hungry:
$2.00
$5.00
$10.00
$20.00
$50.00
$__________.____
TOTAL AMOUNT DUE
Proof of Residency:
Please include a photocopy of ONE of these documents.
Required to confirm residency by providing a readable photocopy of one of the documents listed below
Valid State issued driver’s license
Valid State issued Identification card
Permanent and Total Disability
Required documentation
Defined under Code of Virginia
§ 58.1-3217. Permanently and totally disabled defined.
For purposes of this article, the term "permanently and totally disabled" shall mean unable to engage in any substantial
gainful activity by reason of any medically determinable physical or mental impairment or deformity which can be expected
.
to result in death or can be expected to last for the duration of such person's life
I have included my Physician’s Affidavit for a Disabled Lifetime License from a licensed physician.
The physician’s affidavit form can be found on our website at:
http://www.dgif.virginia.gov/forms/PERM/PERM-
034.pdf
address or you may call VDGIF License Sales and Information at 1-866-721-6911 to obtain the form.
Applicant’s Certification
By signing this application, I certify that in accordance with Virginia Code § 58.1-3217. Permanently and totally disabled
defined. NOTE: Any person who knowingly makes a false statement in order to secure a license shall be guilty of a Class
2 misdemeanor, punishable by up to six months in jail, a fine of up to $1,000 or both.
Signature: _____________________________________________ Date: _____________________________
LTL-NONDIS 0818
Page 1 of 2
Instructions:
(Please allow up to 45 days for processing)
Complete all information on this application.
Select the license(s) you wish to purchase.
Verify that you have included copies of all required documents from items 1 and 2 on this page.
Sign and date the application.
Include a PERSONAL CHECK, MONEY ORDER or CASHIER’S CHECK made payable to the
TREASURER OF VIRGINIA.
Return this application along with all supporting documents and payment to:
Department of Game and Inland Fisheries
Attention: Lifetime License Sales
P.O. Box 2978
Henrico, VA 23228-9700
Information:
• A Saltwater Fishing license is NOT required for persons age 65 and older, however if 65 or older and not
possessing a paid saltwater license, a no cost Fisherman Identification Program (FIP) registration is required:
Please visit
http://www.mrc.virginia.gov.
For information on the FIP program please call (757) 247-2200.
A holder of a disabled lifetime non-resident saltwater fishing license may not fish in designated
freshwater areas without a valid freshwater fishing license. Please see the Virginia Freshwater Fishing
guide for freshwater/saltwater demarcation lines.
Please visit
http://www.mrc.virginia.gov/recreational.shtm
website for recreation saltwater fishing
regulations and information.
LTL-NONDIS 0818
Page 2 of 2
D
G
I
F
EPARTMENT OF
AME AND
NLAND
ISHERIES
L
L
S
IFETIME
ICENSE
ALES
P.O. B
2978
OX
H
, VA 23228
ENRICO
866-721-6911
(Hearing impaired call TDD# 804-367-1278)
Physician’s Affidavit for a Disabled Lifetime License
If you need assistance, contact us at 1-866-721-6911 or for the hearing impaired TDD: 804 367-1278
___________________________________________________________________________________________
I hereby swear, under penalty of perjury that I
, am a licensed physician or
____________________________
(Physicians name-please print)
certified nurse practitioner for
, and do hereby certify the applicant
_________________________________
(Patients full name-please print)
herein named to be Permanently and Totally disabled as defined by Code of Virginia§ 58.1-3217:
Permanently and totally disabled defined-For purposes of this article, the term "permanently and totally disabled"
shall mean unable to engage in any substantial gainful activity by reason of any medically determinable physical or
mental impairment or deformity which can be expected to result in death or can be expected to last for the duration
of such person's life.
By signing this statement I certify that the information provided below is true and correct and that I am
currently a licensed physician in
____________________________________.
(State-please print)
Physician’s Signature:
Date:
____________________________________________________
_________________________
(please print)
Name:
________________________________________________________________________________________________
Address:
_______________________________________________________________________________________________
City:
State:
ZIP Code:
______________________________________
__________________
____________________
Date of Birth:
Gender:
Male
Female
______________________________________
An examination of the above named individual was conducted on
___________________________________________.
(Exam Date-please print)
Provide a brief description of the permanent and total disability for this person below:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
(please print)
Physician’s Name:
________________________________________________________________________________________
First
Middle Initial
Last Name
Name of Business/Practice:
_______________________________________________________________________________
Address:
________________________________________________________________________________________________
City:
State:
Zip:
_________________________________________________
_______________
____________ - _________
Office Phone Number
Office Fax Number:
: ________________________________
____________
PHYAFF-0818
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