Fillable Form 1: r----------- I 1 - Columbine Annual (Colorado Judicial Branch)

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Form 1: r----------- I 1 - Columbine Annual (Colorado Judicial Branch)

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  • 7 check-boxes
  • 32 other fields

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File type: PDF

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C OLO R ADO P AR K S & W I L DLI F E
Columbine License & Pass Application
LIVE LIFE OUTSIDE
Colorado Parks and Wildlife offers the Columbine program for customers with disabilities. These customers qualify for
a free Lifetime Fishing License as well as qualify to purchase a reduced-cost annual parks pass. To qualify, customers
must be Colorado residents and have a total and permanent
disability. Please fill out this checklist and application in its
entirety to expedite your request.
Program Qualification Checklist:
Submit applications and documentation
Requested Product(s): Please mark which product(s) you are applying for
to disability.apps@state.co.us
OR mail to:
Columbine Annual Parks Pass
Colorado Parks and Wildlife
o If mailing in application, please include check or money order
Attn: Columbine Program
for $14, payable to CPW.
6060 Broadway
Columbine Lifetime Fishing License
Denver, CO 80216
Residency Proof:
the below are required to prove Colorado residency for this program
Applicant has lived in Colorado for at least six (6) consecutive months immediately prior to the date of application, AND
Applicant* has a valid Colorado driver’s license or Colorado state ID.
*Applicant is a youth; please provide parent or legal guardian’s Colorado driver’s license or state ID #: ____________________
Total and Permanent Disability Proof
“Final Admission of Liability” form from the Division of Workers Compensation which indicates the applicant has a
“permanent total disability” OR
A completed “Physician’s Affidavit” provided on the second page of this form.
Without proper documentation, we will be unable to process your application. Please be sure to fill out the application legibly and
completely. Any missing information will delay processing of your request and may result in your application being denied.
CID
Legal First Name
Legal Middle Name
Legal Last Name
Physical Address
City
State
Zip
Phone
Email
CO
Mailing Address
Date of Birth
Gender
Weight
Height
Hair Color
Eye Color
Colorado Driver s License or ID #
Month & Year Started Living in CO
Social Security Number
Hunter Education Number & State
Month ______ Year _______
I certify that the information provided on this application and any provided documentation is true and accurate. I hereby authorize
Colorado Parks and Wildlife to make further inquiries to verify information provided on this affidavit which may include contacting
my physician, physical, occupational, or recreational therapist. I understand that any false statements made will void my license
and/or pass and may result in criminal charges.
Signature of Applicant ___________________________________________________________ Date ____________________________
COLORADO PARKS & WILDLIFE • 6060 Broadway, Denver, CO 80216 • (303) 297-1192 • cpw.state.co.us
click to sign
signature
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Physician’s Affidavit of Total & Permanent Disability
To be completed ONLY by a licensed physician for applicants without a “Final Admission of Liability” form.
For this program, the Attorney General has defined a total and permanent disability as any “physical or mental
impairment which prevents substantial gainful employment, but only if it is reasonably certain that such a disability
will continue throughout the lifetime of the person with the disability”.
Physician: please complete the below affidavit certifying that your patient has a total and permanent disability to the
fullest extent of your medical knowledge; see definition above for guidance if necessary. The affidavit may be filled
out by hand or a stamp may be used. Affidavit must be filled out legibly and completely
.
Physician s Name
Physician s License Number
Clinic Name
Clinic Full Address (Street, City, State, Zip)
Clinic Phone Number
Patient’s Name
Date of Diagnosis
OR (Must include license number if not on stamp)
Physician s Stamp
Patient’s Name
Date of Diagnosis
Please confirm your certification by initialing next to each statement below and sign
_______ I certify that I am fully aware of the patient’s medical condition AND
_______ I certify that the patient whose name appears on this application has a total and permanent disability as defined above AND
_______ I certify that the statements made and information provided on this affidavit are true and accurate.
I understand that Colorado Parks and Wildlife may conduct further inquiries to confirm the information on this affidavit and that
any false statements made may result in criminal charges.
Signature of Physician ___________________________________________________________ Date ___________________________
Version 2021.06
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Form 1: r----------- I 1 - Columbine Annual (Colorado Judicial Branch)

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Completed 23 June 2021

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