Fill and Sign the North Carolina Disabled Form

Application for Disabled Sportsman Programs for the State of North Carolina Check Appropriate Program(s): [ ] Disabled Access Program (no fee required) [ ] Disabled Sportsman Hunt (no fee required) Name: ________________________________________WRC Customer # _______________ (First) (MI) (Last) Resident Address: ____________________________________________________________ Street City State Zip Mailing Address: ____________________________________________________________ (if different from above) Street or PO Box City State Zip E-mail Address: ____________________________________Telephone: ( ) __________ Date of Birth: ______________________Driver License # ___________________________ (Month Day Year) Signature of Applicant ________________________________ Date ______________ Physician Must Complete Appropriate Medical Certification(s) Below Prior to Submission I. Medical Certification for Disabled Access Permit I hereby certify that __________________ (Name of Applicant) has a physical disability that limits ambulatory mobility to the extent that normal utilization of the game lands is not possible without vehicular assistance. ______________________________ _______________________ __________ Print or Type Medical Doctor’s Name Medical Doctor’s Signature Date _______________________ __________ __________ ________ ____________ Doctor’s Mailing Address City State Zip Telephone II. Medical Certification for Disabled Sportsman Hunt Certification I hereby certify that ___________________ (Name of Applicant) has one or more of the following disabilities: 1. Missing fifty percent (50%) or more of one or more limbs, whether by amputation or natural causes; paralysis of one or more limbs; 2. Dysfunction of one or more limbs rendering the individual unable to perform the task of grasping and lifting with the hands and arms or unable to walk without mechanical assistance, other than a cane; 3. Disease, injury, or defect confining the individual to a wheelchair, walker, or crutches; 4. Legal deafness. ______________________________ _______________________ __________ Print or Type Medical Doctor’s Name Medical Doctor’s Signature Date _______________________ __________ __________ ________ ____________ Doctor’s Mailing Address City State Zip Telephone Mail completed application to: N.C. Wildlife Resources Commission License Section 1707 Mail Service Center Raleigh, NC 27699-1707 Office Location: NCSU Centennial Campus, 1751 Varsity Drive, Raleigh, NC Telephone: (888) 248-6834 Website: www.ncwildlife.org