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 com- bination 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".