Application for Class DT Special
Statewide Hunting & Fishing License
(Persons with a life-threatening condition)
WV Resident
Non-Resident (must provide Nonprofit Organization Information below)
Nonprofit Organization Name
Contact Name Telephone
Last Name: _________________________________________________________________________________
First Name:_____________________________________________________Middle Initial:__________________
Street/Mailing Address: County: _____________________________
City: State: Zip Code: ___________
Email Address:_______________________________________________________________________
Date of Birth:__________________________Height Weight ____________________
Social Security Number:_________________________________ Phone Number: _________________
Driver’s License/Non-Driver’s Number:________________________Expiration Date_____________________
Sex: Eye Color: Hair Color: Hunter Ed. Card Number________________
MEDICAL CERTIFICATE OF TERMINAL CONDITION OR ILLNESS
MUST BE COMPLETED BY A LICENSED PHYSICIAN
Physician Name________________________________Physician License Number________________________
Street Address________________________City______________________State______Zip________________
I certify that this person has a terminal illness or condition that has a high probability of death within two years
Physician Signature Date
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Applicants must be diagnosed by a licensed Physician with a life-threatening condition;
He or she must be under twenty-one years of age;
A Class DT license entitles the holder to hunt and fish in West Virginia;
The licensee must be accompanied by a parent, guardian, or other competent adult who has
written consent from the parent or guardian and be at least twenty-one years of age;
The person assisting the licensee must hold a valid hunting or fishing license appropriate to the
situation;
Non-resident applicants must be diagnosed by a licensed Physician with a life-threatening
condition;
Non-resident applicants must complete this form and it should be submitted by a qualifying
nonprofit organization that offers hunting and fishing experiences.
Mail the completed application, with original signatures to:
WEST VIRGINIA DIVISION OF NATURAL RESOURCES
ATTN: LICENSE SECTION 324 FOURTH AVENUE
SOUTH CHARLESTON, WV 25303
Form # DNR-CR-DT1
Form Date: 12.10.2019
