Disabled Crossbow Permit - New Hampshire Fish and Game ...

NEW HAMPSHIREFISH AND GAME DEPARTMENT11 Hazen Drive, Concord, NH 03301CROSSBOW APPLICATIONBUS1314A/REV. 11/13FOR OFFICE USE ONLYLicense #_______________Date Issued_____________APPLICANT’S SECTIONI hereby make application to the Director of the New Hampshire Fish and Game Dept. for a Permanent Disabled Crossbow Permit:PLEASE TYPE OR PRINT CLEARLY. All incomplete applications will be returned without consideration._____________________________________________________________________________________________________________NAME OF APPLICANTDATE________________________________________________________________________________(______)______________________STREET AND MAILING ADDRESS ADDRESSDAYTIME TELEPHONE_______________________________________________________________________________(______)______________________CITY/TOWN STATE ZIP HOME TELEPHONEDate of Birth_________ Height__________ Weight__________ Age ________ Hair__________ Eyes________ Sex _______I certify that I have a permanent physical disability and as a result of that disability I cannot operate a conventional bow ora compound bow.________________________________________________APPLICANT’S SIGNATUREPermittee subject to penalties for making unsworn false statements under RSA 641:3.______________________________________DATENote: Persons holding a permanent disabled crossbow permit shall not use longbows, recurve bowsor compound bows while hunting game species in New Hampshire.After completing top part, bring this form to your physician.PLEASE TYPE OR PRINT CLEARLYPHYSICIAN’S SECTIONName of Physician __________________________________________________________________________________Mailing Address ___________________________________________________________ Tel. No.___________________Do not certify this applicant unless you are convinced this is a PERMANENT physical disability that meets therequirements of RSA 207:10-c, as written on the back of this form.q I certify that this is a Permanent Physical Disability.Please describe in detail the Permanent Physical Disability: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Indicate how this Permanent Physical Disability prohibits the individual from using a conventional bow or compound bow:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________MD/DOPHYSICIAN’S SIGNATURE______________________________________DATE_This application is subject to review by a medical review board at the expense of the applicant.After completion by physician, send application and $10.00 to: New Hampshire Fish and Game, 11 Hazen Drive, Concord, NH 03301