Fill and Sign the Illinois Disabled for Form

Illinois Standing Vehicle Permit Application for Disabled Hunters Standing Vehicle Permit Application For the purpose for securing a permit to hunt from a standing vehicle, I attest that I am a ___ paraplegic or a person who meets any of the following criteria (please check one) 1 . ___Has a permanent or irreversible physical disability, is unable to ambulate and requires: a wheelchair, walker, one leg brace or external prosthesis above the knee, 2 leg braces or external prosthesis below the knees, 2 crutches or 2 canes for mobility. 2. ___Suffers significantly from lung disease, to the extent that forced expiratory volume for one second when measured by spirometry is less than one liter or arterial oxygen tension is less than 60 millimeters of mercury on room air at rest. 3 . ___Suffers significantly from cardiovascular disease, to the extent that functional limitations are classified in severity as class 3 or 4, according to the standards accepted by the American Heart Association on May 3, 1988,and where physical activity causes discomfort, fatigue, palpitation, dyspnea or anginal pain. 4. ___Has a temporary disability and has restricted ambulation due to: a) a leg, hip or back, or any part thereof casted by a licensed physician. b) post-surgical effects of leg, hip or back surgery. c) Illness or injury. Further, I authorize my physician to furnish medical records regarding my disability, as may be required by the Department, in order to determine my qualification for this permit. I release my physician from any liability or any damages whatsoever in furnishing same. A photocopy of this release will be valid as an original thereof, even though said photocopy does not contain an original writing of my signature. *NOTICE: If you do not complete the application in full, you will not be considered for a standing vehicle permit. The following is my true description: Name (printed): ________________________________________ Date of Birth: ___________ Street (or mailing) Address:___________________________________________________________ City: _____________________County:___________________ State:____________ Zip:_______ Daytime Phone: ( ) - ___________________________ Have you ever been issued a Standing Vehicle Permit in the state of Illinois? _____yes ______no (check one) If you answered yes to the previous question, on what date was the permit issued?  ____________ month _____________ day_____________ year _____________________________________________________________________ Certification: Pursuant to 5 ILCS 100/10-65(c), IDNR must require license applicants to certify as follows: “I hereby certify, under penalty of perjury,” that: (check one) [ ] I am not subject to a child support order. [ ] I am not more than 30 days delinquent in complying with a child support order. [ ] I am more than 30 days delinquent in complying with a child support order. Applicant’s Social Security Number: ____________________________ Disclosure of applicant’s Social Security Number is mandatory pursuant to 42 U.S.C. 666(a)(13) and 5 ILCS 100/10-65 for use under the State’s child support enforcement program. Failure to certify may result in denial of the application/renewal and making a false statement may subject the licensee to contempt of court [5 ILCS 100/10-65(c)]. I hereby certify that the information contained herein is true and accurate to the best of my knowledge. Signature: _________________________________________ Date:____________________ THE FOLLOWING IS TO BE COMPLETED BY A LICENSED PHYSICIAN: I do hereby swear and affirm, under penalty of perjury, that I have personally examined the above named individual, and that by reason of his/her disability, he/she is ___a paraplegic, or ___ is permanently ___temporarily (check one) disabled and meets the aforementioned criteria. Use this space to explain disability in layman’s terms: ___________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ______________________________________________________________________________ Physician’s Name (printed):_______________________________________________ Street (or mailing) Address:________________________________________________ City: _____________________County:___________________ State:____________ Zip:_______ License Number: ________________ Office Phone: ( ) - __________________ Physician’s Signature:______________________________ Date: ______________ Signed and dated before a witness, attesting that above named person is a licensed physician: Witness’ Name (printed):__________________________________________________________ Street (or mailing) Address:__________________________________________________________ City: _____________________County:___________________ State:____________ Zip:_______ Daytime Phone: ( ) -______________________________________ Witness’ Signature: ___________________________________________ Date:_____________ __________________________________________________________________________________ Once this application is validated by the Office of Law Enforcement, you will receive a hard card permit. While you are using this privilege you must comply with Ill. Compiled Statutes Chapter 520, Section 2.33 and Administrative Rules Part 760 and Part 530. You are required to carry this authorization with you while exercising this privilege and must present it to any law enforcement authority. This authorization applies to the individual named above, without restriction as to ownership of the vehicle. If you lose this authorization, you will be required to reapply. Return completed application to : Illinois Department of Natural Resources Office of Law Enforcement One Natural Resources Way Springfield, IL 62702-1271 EQUAL OPPORTUNITY TO PARTICIPATE IN PROGRAMS OF THE ILLINOIS DEPARTMENT OF NATURAL RESOURCES (IDNR) AND THOSE FUNDED BY THE U.S. FISH AND W ILDLIFE SERVICE AND OTHER AGENCIES IS AVAILABLE TO ALL INDIVIDUALS REGARDLESS OF RACE, SEX, NATIONAL ORIGIN, DISABILITY, AGE, RELIGION OR OTHER NON-MERIT FACTORS. IF YOU BELIEVE YOU HAVE BEEN DISCRIMINATED AGAINST, CONTACT THE FUNDING SOURCE’S CIVIL RIGHTS OFFICE AND/OR THE EQUAL EMPLOYMENT OPPORTUNITY OFFICER, IDNR, ONE NATURAL RESOURCES W AY, SPRINGFIELD, IL., 62702-1271; 217/785-0067; TTY 217/782-9175.