Form VCP-410 "Physician's Affirmation as to a Person's Permanent Inability to Walk" - Virginia

What Is Form VCP-410?

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 September 1, 2014;
  • 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 VCP-410 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 VCP-410 "Physician's Affirmation as to a Person's Permanent Inability to Walk" - Virginia

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Virginia Conservation Police
Department of Game and Inland Fisheries
Physician's Affirmation as to a Person's Permanent
Inability to Walk
VCP­ 410 ver. 2014.9
Prerequisite for permit to shoot from vehicle as allowed in § 29.1-521.3 Code of Virginia
TO: Commonwealth of Virginia, Conservation Police / Department of Game and Inland Fisheries
PHYSICIAN'S AFFIDAVIT OF PATIENT'S PHYSICAL EXAM
Physician's Certification (To be completed by physician)
Physician's Name (
:
please print)
Street or R.F.D. Address:
City:
State:
Zip Code:
Briefly describe applicant's disability(s): (use additional sheets if necessary)
Physician's Statement: It is my professional opinion that
(Name of Patient/Applicant)
(Patient's/Applicant's Address)
Patient's Contact Phone Number
Patient's Date of Birth
is permanently unable to walk due to impaired mobility (impaired mobility has been defined as a permanent
inability to walk due to impaired mobility without the use of or assistance from a brace, crutch, prosthetic
device, or wheelchair.) By signing this statement I certify that the information provided in the physician's
statement is true and correct and that I am currently a licensed physician in
(State)
My professional opinion is based upon a physical examination of
(Name of Patient/Applicant)
which I conducted on the
day of
, 20
.
X
(Signature of Examining Physician)
(Date)
Important Notice to Certifying Physician
The permit for which this certification is required is legal only for those persons who are
PERMANENTLY unable to walk due to impaired mobility. It is not for issuance to those individuals with
temporary disabilities or with conditions that limit stamina or physical endurance. Physicians having any
questions regarding this form may call the Conservation Police, Virginia Department of Game and Inland
Fisheries, 804/367-0171.
7870 Villa Park Drive, Suite 400, P.O. BOX 90778, Henrico, VA 23228-0778
(804) 367-1000 (V/TDD) Equal Opportunity Employment, Programs and Facilities
FAX (804) 367-2430
Virginia Conservation Police
Department of Game and Inland Fisheries
Physician's Affirmation as to a Person's Permanent
Inability to Walk
VCP­ 410 ver. 2014.9
Prerequisite for permit to shoot from vehicle as allowed in § 29.1-521.3 Code of Virginia
TO: Commonwealth of Virginia, Conservation Police / Department of Game and Inland Fisheries
PHYSICIAN'S AFFIDAVIT OF PATIENT'S PHYSICAL EXAM
Physician's Certification (To be completed by physician)
Physician's Name (
:
please print)
Street or R.F.D. Address:
City:
State:
Zip Code:
Briefly describe applicant's disability(s): (use additional sheets if necessary)
Physician's Statement: It is my professional opinion that
(Name of Patient/Applicant)
(Patient's/Applicant's Address)
Patient's Contact Phone Number
Patient's Date of Birth
is permanently unable to walk due to impaired mobility (impaired mobility has been defined as a permanent
inability to walk due to impaired mobility without the use of or assistance from a brace, crutch, prosthetic
device, or wheelchair.) By signing this statement I certify that the information provided in the physician's
statement is true and correct and that I am currently a licensed physician in
(State)
My professional opinion is based upon a physical examination of
(Name of Patient/Applicant)
which I conducted on the
day of
, 20
.
X
(Signature of Examining Physician)
(Date)
Important Notice to Certifying Physician
The permit for which this certification is required is legal only for those persons who are
PERMANENTLY unable to walk due to impaired mobility. It is not for issuance to those individuals with
temporary disabilities or with conditions that limit stamina or physical endurance. Physicians having any
questions regarding this form may call the Conservation Police, Virginia Department of Game and Inland
Fisheries, 804/367-0171.
7870 Villa Park Drive, Suite 400, P.O. BOX 90778, Henrico, VA 23228-0778
(804) 367-1000 (V/TDD) Equal Opportunity Employment, Programs and Facilities
FAX (804) 367-2430