FISHING LICENSE
APPLICATION
Print Plainly
P.O. Box 218
Updated 6/9/08
DATE _________________________________ FISHING LICENSE NO.__________________________________
(Official
Use, Issuing Agent Only)
NAME
____________________________________________ PHONE
____________________________________________
ADDRESS
_____________________________________________________________________________________________
CITY__________________________________________
STATE_________________________ ZIP____________________
BIRTHDATE mo.________ day __________ year
___________HEIGHT__________________ EYE COLOR_____________
AGE___________________ SEX____________________Drivers
License No________________________________________
CHECK THE LICENSE DESIRED ¨ Resident
.
$22.70 ¨ Senior Resident (over
65)
11.70 ¨ Senior Resident
Lifetime
..51.70 ¨ One Day
Resident
11.70 ¨ Non-Resident
...
52.70 ¨ One-Day Tourist
.26.70 Valid After May 1st. Date____________ ¨ 7-Day
Tourist
.
.34.70 Valid from _________ to __________ ¨ 3-Day Tourist
..
.. ..26.70 Valid from _________ to___._______ ¨ Natl
Guard/Reservist Resident
.2.70 ¨ POW Resident
...2.70 ¨ POW Sr
Resident Lifetime
..2.70 ¨ Trout/Salmon
Stamp
.. 9.70 ¨ Lake ¨ ComboTrout-Salmon/Lake Erie Permit
.15.70 ¨ Replacement
6.70 Original
Number__________________ Total
..
..
$ ________
*Required
SOCIAL SECURITY # ________________________
Applicant must
establish identity, age, and the fact that he or she
is a bona fide resident of
issuing
agent.
Type of ID
___________________________________________
I certify the above to be a true and
accurate statement.
_____________________________________________________
Applicant's Signature
Cost includes Issuing Agent
Fee $1.00 for each license,
stamp and permit.
¨ *Resident 100% Disabled
War Veteran Claim No. __________________ Free * Available only from