Affidavit

Directions:  If you have chosen to take the Kentucky Department of Fish and Wildlife's certified six (6) hour hunter education classroom training by an alternative method (Video, CD-Rom, Internet, Workbook) instead of attending the live classroom presentation, please print out this form, fill it out and get it notarized. You will need to take this completed form to the range with you to complete the training.

I (the Affiant), _____________________________, certify and declare that in

                              (Student’s Name)

order to obtain a Hunter Education Completion Card pursuant to 301 KAR 2:185 section 4, state as follows:

I have chosen to take the Kentucky Department of Fish and Wildlife’s certified six (6) hour hunter education classroom training by an alternative method, instead of attending the live classroom presentation of the material;

I understand that these six (6) hours of instruction are a required, alternative element before being eligible to attend the four (4) additional hours of range training required for Hunter Education Certification. I also understand that these six (6) hours do not constitute or apply to any certification other than the completion of the Department of Fish and Wildlife Resources Hunter Education Course;

The alternative method successfully completed is checked below:

Video_____   CD-Rom_____   Internet_____   Workbook_____

                                     (Check One)

I hereby further certify that the information that I have provided is full, complete, accurate and in compliance with KRS 150.195, which prohibits any person from making a false statement or providing false information when applying for a license or a permit;

I understand that if I have provided any false information that my license may be revoked and/or suspended temporarily or permanently, and require me to successfully complete the course.

Affiant Name: ______________________________

                       (Please Print Student’s Name)

Address:  _______________________________

_______________________________________

Date of birth:  ____/____/______

Phone:  (____) ____-_____

Sex:  M ____   or F ____

Affiant’s Signature:_______________________________

___________________________________________________________________

NOTARY TO COMPLETE BELOW INFORMATION:

Commonwealth of Kentucky,

County of ______________

I hereby certify that the above information was acknowledged by

______________________________________, before me on this

                    (Student’s Name)

_______ day of _____________, 20_____.

                                                                      ____________________________
                                                                      Notary Public