Name: (Last) _________________________, (First) ______________________ (MI) _______
Street: _______________________________________________________________________
City: __________________________________________ State: ______ Zip: _____________
Street Address (If different from mailing address):
Street: _______________________________________________________________________
City: __________________________________________ State: ______ Zip: _____________
Phone: ________________________________
Drivers License Number: _________________________________________ State: _________
OK Fishing License Number: ____________________________________________________
Vehicle Make: ____________________ Model: ____________ Tag: _________ State: _____
Date(s) When Permit Wanted: ___________________________________________________
____ One day Permit $5.00 ____ One week permit $15.00
____ Annual permit $25.00 (Annual permit good for one year from date of issue)
Signature: ________________________________
Print Name: ______________________________
Fill in the above form and bring it to Medicine Park Town Hall from 8 to 12 or 1 to 5 Monday through Friday, along with cash or check for the correct amount.
You can mail the completed form along with your check, or money order to:
Trout Tournament
Medicine Park Town Hall
P.O. Box 231
Medicine Park, OK 73557
Be sure to include a self-addressed, stamped envelope for returning your permit. Please allow at least a week for mail-in permits to be delivered.