Form 2738 A – Fill Out and Use This PDF

Arizona Game and Fish Department	For Department Use Only
5000 W Carefree Hwy	Date Received ____________Region___________
Phoenix, Arizona 85086	Approved Date __________Denied Date________
(602)942-3000
www.azgfd.gov	Approved By_________________________
Permanent Permit________	Temporary Permit Valid from _________to ___________
	Please Print or Type

***Social Security Number is voluntary to be used for Sportsman’s Database Only***

Application for a Permanent/Temporary Crossbow Permit

Fee: Complimentary

The Arizona Game and Fish Department may issue a Crossbow permit to those who have one or more of the following physical limitations. An amputation involving body extremities required for stable function to use conventional archery equipment; A spinal cord injury resulting in a disability to the lower extremities, leaving the applicant nonambulatory; A wheelchair restriction; A neuromuscular condition that prevents the applicant from drawing and holding a bow; A failed functional draw test that equals 30 pounds of resistance and involves holding it for four seconds; A failed manual muscle test involving the grading of shoulder and elbow flexion and extension or an impaired range-of-motion test involving the shoulder or elbow; or A combination of comparable physical disabilities resulting in the applicant's inability to draw and hold a bow.

Name					Date of Birth		Phone
Mailing Address					City			State		Zip
Physical Address					Resident			Nonresident
Dept. ID/SSN		Email					Champ Permit Number
Gender	Height			Weight		Eyes			Hair
Applicant Signature							Date

It shall be unlawful for any person to obtain by fraud or misrepresentation a license to take wildlife. Such license fraudulently obtained shall be void from the date of issuance. I hereby certify that the above statements are true.

Form 2738-A Revised 1/15

Health Care Provider Certification

I hereby certify that ____________________________________meets the requirements for a Crossbow

Permit.

Indicate whether the disability is temporary or permanent and, when temporary, specify the expected duration of the physical limitation.

Permanent Disability__________________________
Temporary Physical Limitation from Date_______________________	To Date_____________________

Health Care Provider’s Name_________________________________________________________________

(Print Name)

License

Number__________________________________________________________________________________

Name of Medical

Facility__________________________________________________________________________________

Address of Medical

Facility___________________________________________________________________

City______________________________________________State___________________Zip______________

Phone Number_____________________________________________________________________________

Health Care Provider’s

Signature_______________________________________________________Date______________________

Health Care Provider means a person who is licensed to practice by the federal government, any state, or U.S. territory with one of the following credentials: Medical Doctor, Doctor of Osteopathy, Doctor of Chiropractic, Nurse Practitioner or Physician Assistant.

It shall be unlawful for any person to obtain by fraud or misrepresentation a license to take wildlife. Such license fraudulently obtained shall be void from the date of issuance. I hereby certify that the above statements are true.

Form 2738-A Revised 1/15