Response

Veteran Information

First Name

Last Name

Suffix

SSN

Date of Birth

Address Line 1

City

State

Zip

Home Phone

Work Phone

Cell Phone

Disabled Hunting License #

Copy of Complimentary Disabled Veterans Hunting/Fishing License

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DD Form 214 (if not on file with the Bureau already)

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By my signature, I agree to my name being published on MBVS website if my name is drawn for a permit; I further certify that I am allowed by State of Maine and Federal Law to possess a firearm; and that I have not taken a Moose through DVCMH in any previous hunt.

I acknowledge

Signature Date

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