WEST VIRGINIA
Division of Natural Resources and
Department of Health and Human Resources
DEVELOPMENTALLY DISABLED RESIDENT FISHING LICENSE (DDFL) APPLICATION
As a Physician / APRN / PA licensed by the State of West Virginia, I do hereby certify that the following
individual has a developmental disability, pursuant to the criteria specified below:
The term “Developmentally Disabled” as used in W. Va. Code §20-2-28(j) refers to a person with a severe,
chronic disability as described below (check all statements that apply to the applicant):
(1)
(2)
(3)
He/she has a mental or physical impairment, or a combination of mental and physical
impairments;
It was manifested before the person attained age twenty-two;
It has resulted in substantial functional limitations in three or more of the following areas of
major life activity:
Self care;
Learning; Mobility; Receptive and expressive language;
Self-direction; Capacity for independent living; Economic self-sufficiency; and
The individual’s disability is reflected in the person’s need for a combination and sequence
of care, treatment, or supportive services, which are of lifelong or extended duration and
are individually planned and coordinated.
Physician / APRN / PA Signature License Number Date
______________________________________________________________________________________
PRINT Physician / APRN / PA Name
Applicant Information:
Last Name______________________________________First Name_____________________MI_______
Street Address__________________________________________________________________________
City State
Zip Code___________
Birth Date:
/
/
Eye Color:________
Male Female
Sex:
Social Security Number: _____________________Email:_________________________________
Driver’s License or ID # ________________________ Expiration Date: _____________________
Height:______________ Weight:____________ Phone #_________________________________
I hereby certify under penalty of perjury that information provided on this form is true to the best of my
knowledge and belief and that I am now and have been a resident of West Virginia for the past 30 days. I
also hereby authorize the Department of Health and Human Resources to release this form to the Division
of Natural Resources so that the applicant may obtain the free fishing license under the WV Code.
______________________________________________________________________________________
Signature of Applicant, Guardian
Date
I hereby certify that based on the information above, this person meets the criteria for being
developmentally disabled as specified in W. Va. Code §20-2-28(j).
_______________________________________________________________________________________
Secretary, Department of Health and Human Resources Date
(4)
Send completed application, with original signatures to:
West Virginia Division of Natural Resources
Attn: License Section
324 Fourth Avenue
South Charleston, WV 25303
DNR-CR-DDFL1
02.06.2018
Hair Color:_______
