EOEEA-DFG

Name(Required)

First Middle initial Last

MassFishHunt customer ID number(Required)

Date of birth(Required)

MM

DD

YYYY

Address(Required)

Street address Address line 2 City State Zip

Hunter phone number (cell preferred)(Required)

The phone number above is a(Required)

Cell phone

Home phone

Email(Required)

Emergency contact name(Required)

First Last

Emergency contact phone number(Required)

FID or LTC number (required for hunting with a firearm)

FID or LTC expiration date

MM

DD

YYYY

Driver's license number (required if driving a vehicle on base)

Driver's license state abbreviation (ex: MA)

Do you have any medical conditions you would like us to know about?

Select which hunt(s) you want to participate in(Required)

Youth turkey

Spring turkey

Youth deer

Paraplegic deer

Archery deer

Military deer

Shotgun deer

Primitive firearms deer

I understand that I will be subject to a background check prior to being granted permission to access the installation.(Required)

I certify that all information above is true and correct.(Required)