Application For A Central Visual Acuity Disability Permit Form - Wyoming Game And Fish Department
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APPLICATION FOR A CENTRAL VISUAL ACUITY
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DISABILITY PERMIT
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PLEASE PRINT
__________________________________________________________________________________________
NAME
LAST
FIRST
M.I.
MAILING ADDRESS_______________________________________________________________________________________
CITY__________________________________STATE___________ZIP___________
DATE OF BIRTH__________________
XXX-XX-
SOCIAL SECURITY # (Required)
TELEPHONE NUMBER_________________________
SEX_____ WEIGHT________
HEIGHT_________ EYE COLOR_________ HAIR COLOR____________
I hereby swear, under penalty of prosecution, I am permanently disabled as described in this application.
SIGNATURE_______________________________________ _______________
DATE___________________
If a Wyoming Resident, please complete the following Proof of Residency statement:
WY Driver’s License Number or WY ID Card Number
YRS WY RES.
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PHYSICIAN MUST COMPLETE:
I, the undersigned, swear that I am a licensed physician, optometrist or ophthalmologist and find the above named applicant to be
disabled as defined by the following condition:
Has central visual acuity that permanently does not exceed 20/200 in the better eye with corrective lenses, or the
widest diameter of the visual field is not greater than twenty (20) degrees.
NAME____________________________________________________________________________________
PLEASE PRINT
LICENSED PHYSICIAN, OPTOMETRIST, OR OPHTHALMOLOGIST (
)
ADDRESS__________________________________________________________________________________________________
CITY___________________________
STATE________ ZIP______________
Telephone___________________________
_______________________________________________________________
____________________________________
Signature of Licensed Physician, Optometrist, or Ophthalmologist
Date
Permits are issued only at Wyoming Game and Fish Department Regional Offices located in JACKSON, PINEDALE, CODY, SHERIDAN, GREEN
RIVER, LARAMIE, LANDER or CASPER. Applications can be mailed to the headquarters office: License Section, Wyoming Game and Fish
Department, 5400 Bishop Boulevard, Cheyenne WY 82006-0001.
H:\FORMS\AGENTS\Applications\Central Visual Acuity Disability Permit 2013.DOC (08/2013)
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