TENNESSEE WILDLIFE RESOURCES AGENCY

TENNESSEE WILDLIFE RESOURCES AGENCY ? LICENSING DIVISION

MISCELLANEOUS LICENSES APPLICATION

Name ________________________________________________________________________________ Date of Birth ______/______/________

Business Name ________________________________________________________________________ Social Security # ______-____-________

Address ______________________________________________________________________________ TWRA ID# ________________________

City ___________________________________________________ State _______ ZIP ______________ Phone ___________________________

PLEASE PRINT NEATLY INSIDE THE BOXES BELOW

Drivers License # (age 16 or older)

Gender Male

State of Issue

Weight

Female Height

"`

E-mail ___________________________

Hair

Brown

Gray

Black

Bald

Blonde Auburn

Red

White

Eyes

Blue

Black

Brown

Gray

Hazel

Green

CHECK THE APPROPRIATE BOX BELOW

100 Annual Resident Senior Citizen Commercial Fishing License (expires 2/28)....................................................................................................(No charge) 141 Taxidermist Permit (expires 2/28)..................................................................................................................................................................................................$122 168 Resident Annual Hunting & Fishing Disabled Under 18 (expires 2/28)............................................................................................................................... $5 169 Resident Hunting & Fishing Intellect Disabled.............................................................................................................................................. (One-time fee) $10 189 Resident Hunting & Fishing - Wheelchair Restricted Citizens License (TN residents only)........................................................... (One-time fee) $10 190 Sport Fishing Slat Basket Tag: Enter your Combo Hunting & Fishing License number or Sportsman License number.................................. $10 197 Resident Fishing License For The Blind............................................................................................................................................................. (One-time fee) $10 198 Resident Disabled Veteran Hunting & Fishing License............................................................................................................................... (One-time fee) $10 199 Resident SSI Disability Fishing License............................................................................................................................................................. (One-time fee) $10 450 Resident Guide License.....................................................................................................................................................................................................................$150 Replacement Resident Guide License............................................................................................................................................................................................. $8 I (print name)__________________________________________ certify that any other copies of this license have been lost/stolen or destroyed and are no longer in use. (initial) ____________ 455 Non-resident Guide License............................................................................................................................................................................................................$650 Replacement Non-resident Guide License..................................................................................................................................................................................... $8 I (print name)__________________________________________ certify that any other copies of this license have been lost/stolen or destroyed and are no longer in use. (initial) ____________

Mail application, with check or money order to

If paying by credit card, you may... ? FAX your application to 615-837-4262 or ? EMAIL it to twra.miscapplication@.

Tennessee Wildlife Resources Agency P.O. Box 41729

Nashville, TN 37204-1729 1-615-532-0476

PLEASE DO NOT SEND CASH!

__________________________________________________________ Date: __________________ Amount Enclosed: $__________________ Applicant's Signature

Mail signed application along with check, money order, or phone number for credit card payments to the above address.

Please provide a good telephone number by which we may contact you for payment information.

WR-0142 (Rev. 12/17)

DO NOT SEND CASH.

Special Requirements by Type

Type 100 - Free Annual Resident Senior Citizen Commercial Fishing License

This type is issued at no charge to those residents 70 years old or older who furnish proof of residency and age. This license expires every year on the last day of February. Holders of this license must apply yearly.

Type 168 - Resident Annual Hunting & Fishing Disabled Under 18 Available to Tennessee residents under the age of 18 who meet the

requirements of TCA 70-2-104 as amended. The certification of the total and permanent disability issued by a physician licensed to practice in Tennessee must accompany this application. Renewable annually with current fee. Permits where required.

Type 169 - Resident Hunting & Fishing Intellect Disabled Tennessee residents over the age of 10 years may purchase by provid-

ing a certification by a physician licensed to practice in Tennessee as having an intellectual disability as described in TCA 33-1-101. Applicant will be required to complete the Hunter Education Course as provided in TCA 70-2-108. Additional restrictions are listed on the back of the license card.

Type 189 - Resident Hunting & Fishing Wheelchair Restricted Citizens License (TN Residents Only)

In accordance with TCA 70-2-140 (b), I hereby make application for a Sport Hunting & Fishing Wheelchair Restricted Citizens License and agree to surrender this license issued to me should I become ineligible under the provisions below: ? Application for a Sport Hunting & Fishing Wheelchair Restricted Citi-

zens License is only for Tennessee residents restricted to a wheelchair permanently. ? All other permits and/or supplemental licenses such as, but not limited to, Tellico Trout, Gatlinburg Trout and Reelfoot Preservation Permits are required in addition to this license. A certificate from a physician licensed to practice in Tennessee must accompany this application stating applicant is permanently restricted to a wheelchair.

Type 190 - Sport Fishing Slat Basket Tag Name of reservoir or stream where you plan to fish:

_________________________________________________________ Sport fishing basket tags will only be issued to individuals under age

16, over age 65, and those holding a valid annual license. The tag is valid from March 1 until the last day of February. Only one tag will be issued per individual. The tag must be securely fastened to the basket.

Slat baskets may have only one outside funnel opening and may be made of wood, plastic, or cane slats or splits which are placed lengthwise and so constructed that there must be a minimum of four openings in the catching area, each being at least 1-1/2 inches wide and 6 inches long.

Waters open: All public streams and reservoirs. Fish which may be taken: Non-game fish. Creel Limit: Same as sport fishing.

Type 197 - Resident Fishing License for the Blind TCA 70-2-104 (a) (1) provides for the issuance of a sport fishing

license for a fee of $10.00 to those residents of Tennessee who are certified as being blind, having a visual acuity with maximum correction, not exceeding 20/200 but accompanied by a limitation in the field of vision such that the widest diameter of the visual field subtends an angle no greater than twenty (20) degrees. The Executive Director of the TWRA shall accept, as evidence, a certified form from the Department of Human Services or from a physician licensed to practice medicine in this state and who is engaged in the treatment of the human eye, or a licensed registered optometrist certifying such persons meet the requirements of this section with reference to the degree of blindness.

Check which one of the following proofs of blindness is submitted with this application by a certificate from:

( ) Department of Human Services ( ) Ophthalmologists ( ) Optometrist

Type 198 - Resident Disabled Veteran Hunting & Fishing License Required certification of recent date from the Veterans Adminis-

tration must accompany this application. Per TCA 70-2-104 (a) (3a & b), the Director of the TWRA shall accept,

as evidence of war-connected disability, the following three pieces of information from the Veterans Administration:

1. Percent of disability (30 percent disabled by reason of war service or 100 percent service connected)

2. Dates of service 3. Name of war or conflict These three pieces of information must be supplied by the Veterans Administration as separate documents or in the form of a certificate or DD214 form. By signing my signature on this application, I hereby agree to surrender the license issued to me by reason of this disability should I become ineligible under the above provisions.

Type 199 - Resident SSI Disability Fishing License Residents of Tennessee who receive Social Security benefits due to

intellectual disability are entitled to the privilege of sport fishing, per TCA 70-2-104. The TWRA, upon receiving proof of such intellectual disability, shall issue applicant a permanent Sport Fishing License for a $10.00 fee.

Applicant must secure written certification from the Social Security Administration that he/she receives SSI benefits due to intellectual disability. The certification must accompany this application.

Type 450 - Resident Guide License & Type 455 - Non-resident Guide License

A guide is any individual who accepts compensation for providing assistance to another in any act of hunting, fishing and/or trapping and shall be required to possess a guide license in addition to any other required license. Entities employing individuals as guides may purchase such resident and non-resident guide licenses as may be necessary for its employees.

Resident Licenses

A Social Security Number is required to purchase a Tennessee hunting or fishing license.

Resident licenses can be purchased by: ? Persons who possess a valid Tennessee driver's license or Tennessee

state ID issued by the Department of Safety. Tennessee state law requires drivers to obtain a Tennessee drivers license within 30 days of residency. Out-of-state drivers license only accepted, for Military Personnel and Student meeting the criteria below. ? Persons who do not drive or do not possess a valid driver's license from another state, but who have lived in Tennessee for 90 consecutive days with the genuine intent of making Tennessee their permanent home, may prove residency by presenting to a TWRA license agent any two of the following documents: ? current Tennessee voter registration card ? current Tennessee vehicle registration or title ? Form I-94 issued by the US Citizenship & Immigration Service ? current rental/mortgage contract or receipt including deed of sale for property or receipt for payment of Tennessee real estate taxes within last year. ? Military personnel on active duty in this state and their children under the age of 16, who reside with them, regardless of Tennessee resident status. ? Students who are enrolled in a Tennessee school, college or university for at least six months, with student ID.

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