Kansas Resident Lifetime License Application Important - See Instructions on Back

KANSAS RESIDENT LIFETIME LICENSE APPLICATION IMPORTANT - SEE INSTRUCTIONS ON BACK

[ ] $502.50 Hunt or [ ] $69.00 Payment Plan Credit card information VISA MASTERCARD DISCOVER [ ] $502.50 Fish or [ ] $69.00 Payment Plan [ ] $962.50 Combo or [ ] $131.50 Payment Plan CREDIT CARD#______[ ] $502.50 Furharvester or [ ] $69.00 Payment Plan ______(8 payments, due quarterly, CARDHOLDER'S SIGNATURE EXP. DATE includes finance charge.) *Payment Plan applicants: We do not do automatic withdrawals

ONLY KANSAS RESIDENTS ARE ELIGIBLE FOR LIFETIME LICENSE. (see reverse side for definition of resident) COMPLETE ALL SECTIONS. INCOMPLETE APPLICATIONS WILL BE RETURNED.

FULL LEGAL NAME______Last Name First Name Middle Name CURRENT ADDRESS______Street Address (If rural address, include direction from nearest city) Include mailing if different from physical CITY____________STATE____________ZIP CODE________COUNTY______

EMAIL ADDRESS______

HOW LONG HAVE YOU LIVED HERE______TELEPHONE NUMBER (______)______(______)______Area Code Home Area Code Cell Birthdate______Hair Color ______Eye Color______Wt.______Ht.______Sex______Mo Day Year RACE (to be used for identification purposes only) White Black Hispanic/latino Asian Native American/Alaskan

DRIVER'S LICENSE NUMBER______STATE______DATE OF EXPIRATION______(Photo copy of DL is mandatory)

SOCIAL SECURITY NUMBER______HOW LONG A BONAFIDE RESIDENT OF KANSAS______(mandatory) HUNTER EDUCATION NUMBER______STATE WHERE HUNTER EDUCATION RECEIVED______(if issued by a state other then Kansas, need photocopy of card) FURHARVESTER EDUCATION NUMBER______STATE WHERE FURHARVESTER EDUCATION RECEIVED______(if issued by a state other then Kansas, need photocopy of card) PREVIOUS ADDRESS______CITY______STATE______ZIP CODE______Street Address (If rural address, include direction from nearest city)

PERMANENT RESIDENT ADDRESS______CITY______STATE______ZIP CODE______Street Address (If rural address, include direction from nearest city) DID YOU PURCHASE ANY OF THESE LAST YEAR? (check all that apply) HUNT FISH DEER TURKEY

APPLICANT'S OCCUPATION______

EMPLOYER______NAME ADDRESS TELEPHONE # LIST TWO PERSONS (COMPLETE NAME & ADDRESS) OTHER THAN RELATIVES, FOR PROOF OF RESIDENCE

______ADDRESS PHONE # ______ADDRESS PHONE # MILITARY PERSONNEL ONLY (Photo copy of military ID required) STUDENT INFORMATION (Photo copy of student ID or proof of enrollment is required) (1) CURRENTLY STATIONED IN KANSAS ? YES____NO_____ SCHOOL NAME______(2) WHICH STATE DID YOU LIVE IN WHEN SCHOOL ADDRESS ______YOU ENTERED THE MILITARY?______street address (3) BRANCH OF MILITARY______(4) ACTIVE OR RESERVE?______city state zip (5) INSTALLATION?______SCHOOL PHONE # ______

"ANY FALSE STATEMENT OR FALSE INFORMATION MAY CONSTITUTE A MISDEMEANOR, FELONY, OR OTHER BREACH OF LAW". (KSA32-1001-Misdemeanor KSA 21-3711-Felony) I certify under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct and that I, or the above applicant, has been a bona fide permanent resident of Kansas for at least one year immediately preceding the date of this application and that Kansas is my permanent place of habitation.

X______Subscribed and sworn to me before this______day of ______20___ Signature of Applicant (do not print) ______My commission expires______Notary public X______Subscribed and sworn to me before this______day of______20___ Signature of preparer of form if other than applicant ______My commission expires ______Notary public The "date of application" is that date the complete and proper application is received by the department at the Pratt Operations Office.

07/21

KANSAS RESIDENT LIFETIME LICENSE APPLICATION (Hunt, Fish, Combination Hunt/Fish, or Furharvester) INSTRUCTIONS: TYPE OF LIFETIME LICENSE APPLYING FOR: Total price for a hunting ($502.50), fishing ($502.50), furharvester ($502.50) or combination hunt/fish ($962.50). Lifetime licenses may be purchased with payments being made over a two year period in 8 quarterly install- ments. A payment of $69.00 for a hunt, fish, or furharvester will include a $40 finance charge. A payment of $131.50 for a combination hunt/fish will include a $80 finance charge. The first payment must be submitted with the application. If an installment payment is not received within 30 days after it is due, the Department will deem payments in default and will retain any previous payment. Each paid receipt will serve as your annual license. Your permanent lifetime license will not be issued until all payments have been received. FULL LEGAL NAME: Print or type your full legal name. Do not use initials or nicknames. CURRENT ADDRESS: Your present address that is deliverable by post office. COUNTY: Your county of residency EMAIL ADDRESS: Your current email box to which email messages are delivered. HOW LONG HAVE YOU LIVED HERE: List length of time lived at current address. TELEPHONE: List both your home phone & work phone numbers. PERSONAL DESCRIPTION: Give accurate personal description. RACE: Mark an "X" in the correct box. DRIVER'S LICENSE NUMBER: List the State and number of your current drivers license. Photo copy of driver's license is required. DATE OF EXPIRATION: List the date that your current drivers license expires. SOCIAL SECURITY #: List your social security number. (SS# is mandatory) RESIDENT OF KANSAS: The number of years or months immediately preceding the date of your application that you have claimed Kansas as your place of habitation. HUNTER EDUCATION: Only needed if born on or after July 1, 1957. Where did you receive your hunter education? Give number and state of issue. (If issued by a state other then Kansas, need photocopy of card) (applies to hunt or combo hunt/fish purchases only) FURHARVESTER EDUCATION: Only needed if born on or after July 1, 1966. Where did you receive your furharvester education? Give number and state of issue.(If issued by a state other then Kansas, need photocopy of card) (applies to furharvester purchases only) PREVIOUS ADDRESS: Address of your previous residence. PERMANENT RESIDENT ADDRESS: Your address if different than the one that is currently deliverable by post office. DID YOU PURCHASE A HUNT, FISH, DEER, OR TURKEY LICENSE LAST YEAR: Mark an "X" in the correct box(s). APPLICANTS OCCUPATION: List your job title. EMPLOYER: List name, address & telephone # of employer. LIST TWO PERSONS FOR PROOF OF RESIDENCE: List complete name, mailing address, & telephone # of two (2) persons (other than relatives) for proof of residence. This will be a check for residence only. MILITARY PERSONNEL: Fill in information only if you are military. Photo copy of military ID is required STUDENT INFORMATION: Fill in information only if you are a student. Photo copy of student ID or proof of enrollment is required. HAVE APPLICATION NOTARIZED: The applicant should take this application to a Notary Public, who should witness the signing by the applicant, notarize, and stamp it. MAIL FEE AND APPLICATION TO: KANSAS DEPT. OF WILDLIFE & PARKS 512 SE 25th Ave., PRATT, KS 67124-8174 ATTN: Licensing Section Please allow four weeks to process. Questions may be directed to 620-672-0726

"Resident" means any person who has maintained the person's place of permanent abode in this state for a period of one year immediately preceding the person's application for a lifetime fishing, hunting, furharvester or combination hunting and fishing license. Domiciliary intent is required to establish that a person is maintaining the person's place of permanent abode in this state. You must intend to remain a resident of Kansas at the time you submit the application for a lifetime license to have domiciliary intent. Mere ownership of property is not sufficient to establish domiciliary intent. Evidence of domiciliary intent includes, without limitation, the location where the person votes, pays personal income taxes or obtains a driver's license. "The "date of application" is that date the complete and proper application is received by the department at the Pratt Operations Office".

NOTES: 1. Lifetime license holders who hunt migratory game birds (doves, ducks, geese, coots, snipe, rails, gallinules, sandhill crane, and woodcock) will be required to purchase a Migratory Harvest Information Program (HIP) stamp. HIP stamps may be purchased at any department office, county clerk, or license vendor. HIP stamp must be carried on the person and must be signed in ink across the face of the stamp before taking or attempting to take migratory game birds.

2. Persons while hunting with a lifetime license if 16 years of age or older must have in possession a valid Federal Migratory Bird Hunting and Conservation Stamp (duck stamp), and a Kansas Waterfowl Habitat Stamp signed in ink across the face of the stamp before taking or attempting to take ducks, geese or mergansers. These stamps do not have to be affixed to your license, but must be carried on the person.

3. The lifetime hunting license does not include the privilege of hunting big game or wild turkey. A lifetime hunting or combination license holder that leaves the State of Kansas and takes up residency in another state is eligible for small game hunting and may apply for a big game permit (deer, antelope, turkey or elk) in Kansas as a resident. Anyone desiring to obtain a special permit for hunting deer, antelope, elk, or wild turkey may have his/her name placed in the drawing by submitting an application during the announced application period with the proper permit fee enclosed.

4. A lifetime fishing license does not include the privilege of fishing for trout in designated trout waters. A trout permit is required of all anglers fishing in said waters.

5. A Lifetime License is non-transferable.

6. "A person may purchase for another person, who is a resident of Kansas, a lifetime hunting or combination hunt/fish license without that person first having been issued a certificate of competency and safety in the handling of firearms." In addition, a person may purchase for another person, who is a resident of Kansas, a lifetime furharvester license without that person first having been issued a furharvester education course. This will allow the purchase of a lifetime license for a person too young to take the hunter education course or the furharvester education course. They must, however, pass the course before using the license. GIFTS If you would like to purchase a Lifetime License as a gift and do not want them to know, please follow the instructions below. 1. Fill in application completely and correctly. 2. Leave application unsigned by applicant. 3. If form is prepared by person other than applicant, signature of preparer is required. The preparer of the application must sign the application before a notary. 4. Mail application with a note stating license is a gift, instructions where to mail license, phone number to contact for questions & when gift is to be presented. 5. We will return a copy of the application with a gift certificate. After the gift is given, have the applicant sign the application before a notary & return the application to us and we will send the license to the applicant. 07/21