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Disabled Resident Lifetime License Application

LTL-RESDIS-0818 Page 1 of 2 DEPARTMENT OF GAME AND INLAND FISHERIES Lifetime License SALES BOX 2978 HENRICO, VA 23228-9700 866-721-6911(Hearing impaired call TDD# 804-367-1278) Commonwealth of Virginia - Resident Disabled Application for Lifetime License Instructions and Lifetime License Information on page 2 (Allow up to 45 days for processing) All fields with an asterisk * are required below: *Are you a United States Citizen? Yes DGIF Customer ID#: _____ No-If No, Provide your Visa or Green Card #: _____ *Applicant s Name: _____ *Gender: Male Female (Please Print) First Middle Initial Last Name*Virginia Driver s or DMV Identification number last 4 digits: _____ *Last 4 digits of Social Security No: _____*Mailing Address: _____*City: _____State: _____Zip: _____- _____*Physical Address (if different from Mailing): _____*Telephone (Cell, Home, Work, Other): _____- _____-_____ *Date of Birth: _____/_____/_____E-mail Address: _____Please check the License (s) you are applying for:Price Select below the Disabled Lifetime License (s) you are requesting.

• Disabled Saltwater Fishing Lifetime License may not fish in freshwater without a freshwater license. Please see the Virginia Freshwater Fishing guide for freshwater/saltwater demarcation lines. • For additional information on Hunting, Trapping, and/or Freshwater fishing in Virginia please visit our website www.huntfishva.com.

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