Form Ann Vet70 0714 – Fill Out and Use This PDF

DEPARTMENT OF GAME AND INLAND FISHERIES

LIFETIME LICENSES

4010 W. BROAD ST., PO BOX 11104

RICHMOND, VA 23230

866-721-6911

(Hearing impaired call TDD# 804-367-1278)

Virginia Resident/Nonresident Partially Disabled Veteran (70% OR GREATER)

Mail-in Application for Annual Basic Freshwater and Hunting Licenses

(Application Instructions on page 2)

HAVE YOU PREVIOUSLY PURCHASED EITHER OF THESE LICENSES: DISABLED VETERAN’S ANNUAL BASIC FRESHWATER OR ANNUAL BASIC HUNTING

LICENSES?

No

Yes If YES: You have already been approved and are in our VDGIF database. As an alternative to

completing this application, you may contact our customer service office (866) 721-6911 and purchase your license(s) using a MasterCard or VISA credit or debit card.

Mailing Address: ______________________________________________________________________________________________________

City: ________________________________________________________	State: __________ Zip: _______________-______________
Daytime Phone: ___________________________________________	Date of Birth: ________________________________________

E-mail Address: _____________________________________________________________________________________________

Hunter Education Qualification:

Please check ONE box to qualify for a Hunting license.

Select License(s) and Total Amount Due

	RESIDENT		NONRESIDENT			LICENSE TYPE
	#389	$12.00		#390	$24.00	*Annual freshwater fishing license –does NOT include trout.
	#189	$12.00		#190	$56.00	*Annual hunting license – does NOT include the following licenses:
						Bear, deer, turkey; muzzleloader; archery or crossbow.

*Depending on the type of hunting or fishing season, additional license(s) may be required with the partial disabled Annual Veteran’s licenses. Below mark any additional licenses which you would like to purchase, and include all fees in your payment.

List of all additional annual licenses may be found at www.dgif.virginia.gov , the Hunting & Trapping in Virginia Regulations and the Virginia Freshwater Fishing & Watercraft Owner’s Guide.

	RESIDENT		NONRESIDENT			LICENSE TYPE
	#472	$4.00		#472	$4.00	National Forest Permit
	#475	$10.00		#475	$10.00	Migratory Waterfowl Conservation Stamp
	#115	$23.00		#116	$86.00	Bear, Deer & Turkey License (valid - July 1st – June 30th)
	#119	$18.00		#120	$31.00	Archery
	#129	$18.00		#122	$31.00	Muzzleloader
	#355	$23.00		#356	$47.00	Trout

DONATIONS:

	#999					Contribute to Hunters for the Hungry:				$ 2.00	$ 5.00	$ 10.00	$ 20.00	$ 50.00
									TOTAL AMOUNT DUE

ANN-VET70-0714

Page 1 of 2

1)Proof of Residency: Please include a photocopy of ONE of these documents. DO NOT SEND ORIGINALS.

Valid Virginia driver’s license	Virginia voter registration card
Valid Virginia DMV ID card	Certification of Applicant form
	http://www.dgif.virginia.gov/licenses/lifetime/gift.pdf

2)Statement of Service-connected disability 70% or Greater: Please check ONE box to qualify for a Disabled Veteran’s license and note below the supporting documents that you are required to submit.

Note: The Veterans Affair Identification Card is not an acceptable qualifier for this license.

I have included a copy of my Certification of Disability from the U.S. Department of Veterans Affairs which states that I have a Service- Connected Disability with a numeric rating of 70% or greater.

OR

I have utilized and included the DGIF Veterans’ Certificate of Disability alternative form which accompanied this application and it has been processed by the U.S. Department of Veterans Affairs establishing my license qualification. A copy of this completed form is attached.

Applicant’s Certification

By signing this application, I certify that the above information is true and correct and that I have a service connected disability that is 70% or greater as defined by the U.S. Department of Veterans Affairs. 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: _____________________________

INSTRUCTIONS:

•Return completed and signed application with payment, proof of residency, and certification from the U.S. Department of Veterans Affairs for a Service- Connected Disability with a numeric rating of 70% or greater.

•Include a PERSONAL CHECK, MONEY ORDER or CASHIER’S CHECK made payable to the TREASURER OF VIRGINIA or pay using VISA/MASTERCARD by filling out the credit card authorization form below.

•Return this application with all supporting documents and payment to:

Department of Game and Inland Fisheries

Attention: Customer Service

P.O. Box 11104

Richmond, VA 23230-1104

You may also email us at customerservice@dgif.virginia.gov.

	Virginia Department of Game and Inland Fisheries		(For Office use only)
	Credit Card Authorization Form
	Check Credit Card Type
Name Shown on Credit Card: ________________________________________________
Credit Card Number: __________ __________		__________ __________
Expiration Date:	Month: ________	Year: ________
I authorize the Virginia Department of Game and Inland Fisheries to charge my credit card
for the products/services indicated on the enclosed form.
Signature: ______________________________________ Date: ___/___/_____

ANN-VET70-0714

Page 2 of 2

DEPARTMENT OF GAME AND INLAND FISHERIES

LIFETIME LICENSES

4010 W. BROAD ST., PO BOX 11104

RICHMOND, VA 23230

866-721-6911

VETERANS’ CERTIFICATE OF DISABILITY

Purpose: Alternative form to be used by Veterans to certify having a service-connected Disability with a numeric rating of 70% or greater in lieu of any previously issued U.S. Department of Veterans’ Affairs document reflecting qualification.

Veteran, please use this form to certify you have Service-Connected Disability with a numeric rating of 70% or greater.

Instructions: Mail this completed form for validation to:

Veterans’ Services Officer

116 N. Jefferson Street

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VETERAN'S INFORMATION

VETERAN’S NAME: ______________________________________________________________________________

MAILING ADDRESS: _______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

VETERANS’ ADMINISTRATION CLAIM NUMBER: _________________________________________________

__________________________________________________________________________________________________________________________________________________________

DATE: __________________ CONTACT PHONE NUMBER: _________________________

§ 29.1-302.2 Special resident and nonresident hunting license for partially disabled veterans.

Any resident veteran who is rated by the U.S. Department of Veterans Affairs as having at least a 70 percent service-connected disability, upon certification, shall pay an amount equal to one-half the fee for the state resident basic hunting license required by subdivision 2 of § 29.1-303. Any nonresident veteran who is similarly rated, upon certification, shall pay an amount equal to one-half the fee for the state nonresident license required by subdivision 3 of § 29.1-303.

NOTE: PLEASE MAIL THIS COMPLETED FORM BACK TO APPLICANT

CERTVET70-0714