Free 10691.FH11 - Indiana

APPLICATION FOR SPECIAL PERMIT FOR HUNTER WITH DISABILITIES
State Form 10691 (R6 / 7-04)

(Check One)

New

Renewal

INSTRUCTIONS: 1. Please print clearly or type. 2. Provide all information requested or your application will be returned without processing. 3. A Physicians Statement of Disability must accompany each application submitted by new applicants. 4. Mail forms to: DIVISION OF FISH AND WILDLIFE DISABILITY SECTION 402 WEST WASHINGTON STREET ROOM W273 INDIANAPOLIS IN 46204 APPLICANT INFORMATION
Name of applicant Address (number and street) City, state, ZIP code County Date of birth (month, day, year) Height Eyes Telephone number Sex

Male
Weight Hair

Female

( DESCRIPTION OF DISABILITY AND REQUEST
Describe your disability:

)

With a Disabled Hunter Permit, describe exactly your requested method of hunting:

Signature of applicant

NOTE: Please include the type of transportation (car, truck, 4-wheel drive vehicle, ATV); method of taking game (shooting from a vehicle, etc.) and w e a p o n ( s h o t g u n , m u z z l e - l o a d i n g r i f l e , b o w, c r o s s b o w ) .

Date (month, day, year)

FOR OFFICE USE ONLY
Reason For Disapproval

Application Approved

Application Disapproved
Date (month, day, year)

Signature of Fish and Wildlife Committee Chairman