FORM 2729 Revised 2/17 FOLE

ARIZONA GAME AND FISH DEPARTMENT5000 W Carefree Hwy

Phoenix, AZ 85086-5000 APPLICATION FOR DISABLED VETERAN'S LICENSE

R12-4-202

FOR DEPARTMENT USE ONLY

VA letter attached Dept Veterans Services Cert attached

Approved By:___________________________

Date Received: ________________ Region: ______________

Denied:

Date:___________________

Approved:

Date card issued

License # DV

Yes NoPlastic Card

FEE: NONE

[PLEASE PRINT OR TYPE]

Department ID Number or SSN:

Resident

The Arizona Game and Fish Department may issue a complimentary Disabled Veteran's License to a veteran who is receiving compensation for a 100% service-connected disability. The Veteran must be a domiciled resident of Arizona for one or more years. A disabled veteran's license is valid for 3 years from the date of issuance if disability requires reevaluation. License is lifetime if the disability does not require reevaluation of the veteran. A Disabled Veteran's License grants all of the privileges of a Combination Hunting and Fishing License and the Urban Fishing License. All other stamps and tags must be purchased separately.

Physical Address (if different than mailing) Email

Applicant's Signature Date

Number of Years Resident

Name Mailing Address

Eyes Hair Height WeightGender Phone ZipState City

Date of Birth

*Optional: Hard Plastic permanent card may be purchased for $4.00. Customer will be mailed a card within 30 days after application is processed. Card is only available to veterans with a permanent 100% disability. If original hard plastic permanent card is lost the cost of duplicate is $4.00.

**The SSN is required by the Department of Veteran's Services to complete certification form**

It is unlawful for any person to obtain by fraud or misrepresentation a license to take wildlife. Any license fraudulently obtained is void from the date of issuance. By signing this document I affirm that I meet the eligibility requirements of this rule and the information provided on the application is true and accurate and that I am a veteran of the armed forces of the US and have been a resident of AZ for one or more years prior preceding application for this license and am receiving compensation from the US government for permanent service connected disabilities rated as 100% disabled. I am not receiving any residency privileges in another state. It is unlawful for any person to obtain by fraud or misrepresentation a license to take wildlife. Any license fraudulently obtained is void from the date of issuance.

ARIZONA GAME AND FISH DEPARTMENT 5000 W Carefree Hwy

Phoenix, AZ 85086-5000 APPLICATION FOR DISABLED VETERAN'S LICENSE

R12-4-202

FORM 2729 Revised 2/17 FOLE Veterans Application Page 2

DEPARTMENT OF VETERANS SERVICES CERTIFICATION

I hereby certify that____________________________________________, Date of Birth___________________, is receiving compensation for a 100% permanent service-connected disability and that (check one)

Address

State Zip

Phone

Name

Date Signature of Agent

Title

City

AN APPLICANT FOR A DISABLED VETERAN'S LICENSE MUST SUBMIT AN ORIGINAL CERTIFICATION ISSUED FROM THE DEPARTMENT OF VETERANS SERVICES.

This person's disabilities are rated at 100% and permanent and will not require reevaluation.

(License will not expire) This person's disabilities are rated at 100%, but the rating will be reevaluated within 3 years.

(License valid for 3 years)

This person's disabilities are rated at less than 100%. Eligibility is not based on % of compensation received.

(Ineligible)

CERTIFYING AGENT OF THE DEPARTMENT OF VETERANS SERVICES

An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by a statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or condition. This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable attorney fees, damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section. A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal pursuant to the Agency's adopted personnel policy. This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.