Affidavit of Previous License
New York State Department of Environmental Conservation
Affidavit of Previous License
Please Print Legibly
(Applicant Name and Date of Birth)
New York State Department of Environmental Conservation from the dates of:
, hereby affirm under penalty of perjury that I have previously issued a
while acting as a License Issuing Officer for the
(Full Name)
sporting license to
to
I may be contacted at the following telephone number if further information is required:
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Please select the type ofliC~I1~~.eYOU pr~~ouslyissue
you do not rememberisSuUig1heJicenseJ"
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All license types MUST becsel~'C'tell.. .
;'XES
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(License Issuing Officer Signature)
* Applicant Must Complete Prior to Purchase*
I he~~bYaJfmn under penalty of perjury that I
*CiT~~.;~.,~s\ling Officer l\(J}#S'
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Affidavit accept~d by
(Name.ota~cepting.ticeiiseISs\Jiil:g;~1!ii'iQ
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(License Issuing Officer Signature)
*Issuing Agent must mail this affidavit to the address listed below within thirty (30) days of
license issuance:
NYSDEC License Sales
625 Broadway
Albany, New York 12233-4790
This is affidavit is proof of sportsman eligibility. This is NOT proof of successful completion of a
Sportsman Education Course.
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