Wr 0142 Form – Fill Out and Use This PDF

Mail application, with check, money order, or credit card information (see below) to

If paying by credit card, you may FAX your application and any special requirements,

as listed on the back of this form, to 615-837-4262.

Tennessee Wildlife Resources Agency

P.O. Box 41729

Nashville, TN 37204-1729

1-800-648-8798

PLEASE DO NOT SEND CASH!

__________________________________________________________

Applicant’s Signature

Date: __________________ Amount Enclosed: $__________________

Mail signed application, proof of residency and special

requirements along with your check, money order, or credit card information to the above address. DO NOT SEND CASH. (See back of application for detailed information.)

APPLICANT SOCIAL SECURITY #: _________-_______-___________

CREDIT CARD INFORMATION: To charge your purchase to VISA, Mas- terCard or Discover card you must complete the information below.

VISA	Expires (mm/yyyy)
Mastercard
Discover
Cardholder’s Signature (required)

__________________________________________________________

Credit Card Account #

Type 168 - Resident Annual Hunting & Fishing Disabled Under 18

Available to Tennessee residents under the age of 18 who meet the requirements of TCA 70-2-104 as amended. The certiication of the total and permanent disability issued by a physician licensed to practice in Tennessee must accompany this application. Renewable annually with current fee. Permits where required.

Type 169 - Resident Hunting & Fishing Intellect Disabled

Tennessee residents over the age of 10 years may purchase by pro- viding a certiication by a physician licensed to practice in Tennessee as having an intellectual disability as described in TCA 33-1-101. Applicant will be required to complete the Hunter Education Course as provided in TCA 70-2-108. Additional restrictions are listed on the back of the license card.

Type 189 - Resident Hunting & Fishing Wheelchair Re- stricted Citizens License (TN Residents Only)

In accordance with TCA 70-2-140 (b), I hereby make application for a Sport Hunting & Fishing Wheelchair Restricted Citizens License and agree to surrender this license issued to me should I become ineligible under the provisions below:

•Application for a Sport Hunting & Fishing Wheelchair Restricted Citi- zens License is only for Tennessee residents restricted to a wheelchair permanently.

•All other permits and/or supplemental licenses such as, but not limited to, Tellico Trout, Gatlinburg Trout and Reelfoot Preservation Permits are required in addition to this license.

A certiicate from a physician licensed to practice in Tennessee

must accompany this application stating applicant is permanently restricted to a wheelchair.

Type 190 - Sport Fishing Slat Basket Tag

Name of reservoir or stream where you plan to ish:

_________________________________________________________

Sport ishing basket tags will only be issued to individuals under age 16, over age 65, and those holding a valid annual license. The tag is valid from March 1 until the last day of February. Only one tag will be issued per individual. The tag must be securely fastened to the basket.

Slat baskets may have only one outside funnel opening and may be made of wood, plastic, or cane slats or splits which are placed length- wise and so constructed that there must be a minimum of four open- ings in the catching area, each being at least 1-1/2 inches wide and 6 inches long.

Waters open: All public streams and reservoirs.

Fish which may be taken: Non-game ish.

Creel Limit: Same as sport ishing.

Type 197 - Resident Fishing License for the Blind

TCA 70-2-104 (a) (1) provides for the issuance of a sport ishing license for a fee of $10.00 to those residents of Tennessee who are certiied as being blind, having a visual acuity with maximum correc- tion, not exceeding 20/200 but accompanied by a limitation in the ield of vision such that the widest diameter of the visual ield subtends an angle no greater than twenty (20) degrees. The Executive Director of the TWRA shall accept, as evidence, a certiied form from the Department of Human Services or from a physician licensed to practice medicine in this state and who is engaged in the treatment of the human eye,

or a licensed registered optometrist certifying such persons meet the requirements of this section with reference to the degree of blindness.

Check which one of the following proofs of blindness is submit- ted with this application by a certiicate from:

() Department of Human Services

() Ophthalmologists

() Optometrist

Type 198 - Resident Disabled Veteran Hunting & Fishing

License

Required certiication of recent date from the Veterans Adminis- tration must accompany this application.

Per TCA 70-2-104 (a) (3a & b), the Director of the TWRA shall accept, as evidence of war-connected disability, the following three pieces of information from the Veterans Administration:

1.Percent of disability (30 percent disabled by reason of war service or 100 percent service connected)

2.Dates of service

3.Name of war or conlict

These three pieces of information must be supplied by the Veterans Administration as separate documents or in the form of a certiicate or DD214 form.

By signing my signature on this application, I hereby agree to surrender the license issued to me by reason of this disability should I become ineligible under the above provisions.

Type 199 - Resident SSI Disability Fishing License

Residents of Tennessee who receive Social Security beneits due to intellectual disability are entitled to the privilege of sport ishing, per TCA 70-2-104. The TWRA, upon receiving proof of such intellectual disability, shall issue applicant a permanent Sport Fishing License for a $10.00 fee.

Applicant must secure written certiication from the Social Security Administration that he/she receives SSI beneits due to intellectual dis- ability. The certiication must accompany this application.

Resident licenses can be purchased by:

•Persons who possess a valid Tennessee driver’s license or Tennessee state ID issued by the Department of Safety. Tennessee state law requires drivers to obtain a Tennessee drivers license within 30 days of residency. Out-of-state drivers license only accepted, for Military Personnel and Student meeting the criteria below.

•Persons who do not drive or do not possess a valid driver's license from another state, but who have lived in Tennessee for 90 consecu- tive days with the genuine intent of making Tennessee their perma- nent home, may prove residency by presenting to a TWRA license agent any two of the following documents:

–current Tennessee voter registration card

–current Tennessee vehicle registration or title

–Form I-94 issued by the US Citizenship & Immigration Service

–current rental/mortgage contract or receipt including deed of sale for property or receipt for payment of Tennessee real estate taxes

within last year.

•Military personnel on active duty in this state and their immediate families, who reside with them, regardless of Tennessee resident status.

•Students who are enrolled in a Tennessee school, college or univer- sity for at least six months, with student ID.