PLEASE DO NOT SEND CASH_ by fdh56iuoui

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									             APPLICATION FOR TENNESSEE RESIDENT LIFETIME SPORTSMAN LICENSE
Please print neatly and clearly with black or blue ink using all   TWRA Sales Office                  CHECK THE APPROPRIATE FEE CATEGORY:
capital letters. Include check or money order made payable to      P.O. Box 41729
TWRA. If paying by credit card, please provide the information                                              $200.00           Applicants under three (3) years of age
                                                                   Nashville, TN 37204-1729
requested at bottom right of this form. Return to:
                                                                   Phone: 1-800-648-8798                    $540.00           Applicants three (3) years of age but less than seven (7)
                                                                   Fax: 615-837-4262                                          years of age
            ADDRESS OF LICENSE HOLDER
First name and middle initial (example: WILLIAM H)
                                                                                                            $810.00           Applicants seven (7) years of age but less than thirteen (13)
                                                                                                                              years of age

Last name and suffix (example: JACKSON SR)                                                                  $1,620.00         Applicants thirteen (13) years of age but less than fifty-one
                                                                                                                              (51) years of age

                                                                                                            $945.00           Applicants fifty-one (51) years of age but less than sixty-five
Address                                                                                                                       (65) years of age

                                                                                                            $270.00           Applicants sixty-five (65) years of age or older
City                                                                                                  Must complete information in this box if 16 years of age or older.

                                                                                                             Weight                         Hair                          Eyes
State              ZIP Code                                                                                                     Brown              Gray        Blue              Black
                                                                                                                                Black              Bald        Brown             Gray
                                                                                                             Height
                                                                                                             ‘              “
                                                                                                                                Blonde             Auburn      Hazel             Green
         COMPLETE ONLY IF MAILING ADDRESS IS DIFFERENT FROM ABOVE                                                               Red                White
First name and middle initial
                                                                                                            Gender                           Month          Day                  Year

Last name                                                                                             M          F          Date of Birth

                                                                                                      LICENSE HOLDERS UNDER AGE 16 MUST INCLUDE
                                                                                                      A COPY OF BIRTH CERTIFICATE.
Address
                                                                                                      TWRA ID #


City
                                                                                                      Area Code & Telephone #


State              ZIP Code
                                                                                                      Date of Hunter Education Class




I certify, under penalty of law, by my signature that I am a resident of Tennessee and meet the 12-month residency requirement
as defined below and all the information provided herein is correct. (If applicant is a minor, a parent or guardian must sign.)


SIGNATURE OF APPLICANT_________________________________________________________________________________                                            DATE ____________________________

MESSAGE AS DESIRED ON CERTIFICATE




License Applicant’s Social Security # (required)




                                                                                                          CREDIT CARD INFORMATION
                            LICENSE REQUIREMENTS                                                          To charge your purchase to VISA, MasterCard or Discover card you must
PROOF OF RESIDENCY (one of the following options)                                                         complete the information below.
  • Copy of Tennessee Driver’s License (must show 12 months                                                      VISA                              Expires (mm/yyyy)
    of residency)
  • Voter’s Registration Card                                                                                    Mastercard
  • Tennessee Safety Identification Card                                                                         Discover
IF APPLICANT IS UNGER AGE 16                                                                              Cardholder’s Signature (Required)
   • Copy of applicant’s birth certificate
   • Parent or legal guardian must provide proof of residency (see above)
                                                                                                          ____________________________________________________________

            PLEASE DO NOT SEND CASH!                                                                      Credit Card Account #
WR-0760
RDA2340 (Rev. 12/10)

								
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