Certificate of Military Active Service Status
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
SPORTING LICENSE APPLICATION
CERTIFICATION OF MILITARY ACTIVE SERVICE STATUS
1. NAME:
(LAST)
(FIRST)
. (MIDDLE)
2. ADDRESS:'
3. CITY/STATE/ZIP:
4. TELEPHONE NO.: (-,-- )_-
:
. Please CHECK (./) the component of Armed Services that applies to you and CmCLE the branch.
I._NY Organized Militia: NY ARMY NATIONAL GDARD NY NAVAL MILITIA
NY AIR NATIONAL GUARD NY GUARD
2._U.S. Reserve Member: ARMY . NAVY MARINES
AIR FORCE '. COAST GUARD
3._Fu1I-timeU.S. Armed Services:. ARMY NAVY MARINES
AIR FORCE COAST GUARD
· Must be a NYS Resident stationed outside NY who will be in NY for no longer than 30
days for either leave or furlough.
Name of Commanding Officer: (print)
Telephone No.: (_)_-
AFFIDAVIT
I
(name)
(grade/rank)
. . hereby affirm under penalty of perjury that I am an active
drilling member of or on full-time active duty in one of the Armed Services listed above in
. the
located at'.
(unit name)
(City/fownlState )
/ /s/ /
Signature
Date: